Sponsor's Notice of Change of Address Form
Page 4 of 5Form I-865 07/17/15 N
I am not an attorney or accredited representative
but have prepared this notice on behalf of the
sponsor and with the sponsor's consent.
I am an attorney or accredited representative and
my representation of the sponsor in this case
7.a.
7.b.
Preparer's Statement
extends does not extend beyond the
preparation of this notice.
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this notice, you must
submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited
Representative, with this notice.
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this notice on behalf of, at the request
of, and with the express consent of the sponsor. I completed
this notice based only on responses the sponsor provided to me.
After completing the notice, I reviewed it and all of the
sponsor's responses with the sponsor, who agreed with every
answer on the notice. If the sponsor supplied additional
information concerning a question on the notice, I recorded it on
the notice.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
Preparer's Signature
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Notice, If Other Than the Sponsor
(continued)
Page 4/5
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