Form I-698 - Application To Adjust Status From Temporary To Permanent Resident (Under Section 245a Of The Ina) Page 8

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A-
Part 7. Contact Information, Statement, Certification, and Signature of the
Person Preparing This Application, If Other Than the Applicant (continued)
Preparer's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Fax Telephone Number
6.
Preparer's Email Address (if any)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this application on behalf of the applicant
and with the applicant's consent.
B.
I am an attorney or accredited representative and my representation of the applicant in this case
extends
does not extend beyond the preparation of this application.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you
must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.
Preparer's Certification
By my signature, I certify, swear or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and
with the express consent of, the applicant. I completed this application based only on responses the applicant provided to me. After
completing the application, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer on the
application. If the applicant supplied additional information concerning a question on the application, I recorded it on the application.
I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant and the applicant
has informed me that he or she understands the ASC Acknowledgement.
Preparer's Signature
8.
Preparer's Signature
Date of Signature (mm/dd/yyyy)
Page 8 of 9
Form I-698 03/03/17 Y

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