Sponsor's Notice of Change of Address Form
Page 3 of 5Form I-865 07/17/15 N
Interpreter's Certification
I have read to this sponsor every question and instruction on
this notice, as well as the answer to every question, in the
language provided in Part 3., Item Number 1.b.; and
I certify that:
which is the same language provided in Part 3., Item Number
1.b.;
I am fluent in English and
The sponsor has informed me that he or she understands every
instruction and question on the notice, as well as the answer to
every question, and the sponsor verified the accuracy of every
answer.
,
Part 4. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Interpreter's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
3.g.
Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)5.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)6.b.
Interpreter's Signature6.a.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f.
Postal Code 3.g.
Country
Province
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Notice, If Other Than the Sponsor
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Preparer's Contact Information
6. Preparer's Email Address (if any)
4. Preparer's Daytime Telephone Number
5. Preparer's Fax Number
Page 3/5
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