Attachment A

Attachment A CERTIFICATION FOR CONTINUED PRESENCE BY REQUESTING LAW ENFORCEMENT AGENCY TO: Unit Chief Parole and Law Enforcement Programs Unit Homeland Security Investigations U.S. Immigration and Customs Enforcement FROM: SAC FBI, New York Field Office RE: Request for Continued Presence for: SAC of the FBI New York Field Office concur in this request and certify, in accordance with the Department of Homeland Security (DHS)'s procedures for Continued Presence, that: 1. The justification and information concerning the request for Continued Presence are accurate and complete. 2. Documentation is attached certifying that the alien is a victim of a severe form of trafficking and may be a potential witness to that trafficking. 3. Name checks have been completed in the principle law enforcement databases on the person named in the request (National Crime Information Center and any other databases available) and, as appropriate, information from foreign law enforcement agencies. Criminal history check results based on fingerprints have been received and any identification issues resolved. [For the FBI: Coordination has also been effected with appropriate member agencies of the Intelligence Community] 4. Copies of all database screens on the person named above, including negative responses, have been identified and forwarded to U.S. Immigration and Customs Enforcement, Homeland Security Investigations, Parole and Law Enforcement Programs Unit. 5. No promises have been made to the Victim that he or she will remain in the United States beyond the authorized period of Continued Presence. 6. An active investigation is underway by a law enforcement agency that requires the assistance of this subject. Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA00173740 Signature [of Authorizing Official] Date Printed Name [of Authorizing Official] Title [of Authorizing Official] Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY! LAW ENFORCEMENT SENSITIVE EFTA00173741 DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE 'POPfliffoYminifion'ronttO\Vatitt 1. Name: (Last) (First) 2. Date of Birth (mo., day, yr) 3. Country of Birth 5. Alias(es) 8. Passport Number 11. Social Security Number (Middle) 4. Country of Citizenship 6. Gender (check one) 7. Alien Number (A#) O Male ❑x Female A 9. Country of Issuance 10. Expiration Date (mo., day, yr.) Part B: Requatinertgency Information 'Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: (First, Last) (include area code) 2. Daytime telephone number 3. Fax number Ext. 2. Case Agent where the Victim resides (if the Victim resides in a jurisdiction other than that of the Lead Case Agent): (First, Last) Supplemental Information: 2. Daytime telephone number 3. Fax number (include area code) Requesting Agency: Federal Bureau of Investigation Group Supervisor's name (First, Last) Daytime telephone number (including area code) +1 Fax number Ext. Victim-Witness Specialist's/Coordinator's name (First, Last) Daytime telephone number (including area code) + Fax number ext. ext. Request for Continued Presence FOR OFFICIAL USE ONLY I LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA00173742 Part C: Case information *Note: Please complete all Information below. 1. Is the Victim currently in the United States? D Yes 0 No 2. The Victim's current immigration status: 3. Is the Victim requesting Continued Presence based upon a pending civil action under 18 U.S.C. § 1595? 0 Yes El No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? 0 Yes 0 No (if yes, where and when) City, State: 5. When did the Victim enter the United States? 6. Through which Port of Entry did the Victim enter the United States 7. How did the Victim enter the United States? Flight Part D: Specific Information Pertaining to the Victim. Please answer each question as completely as possible (Attach additional sheet(s), if necessary.) 1. Significance and value of the Victim to this case: (Please provide a brief explanation of how the Victim meets the definition of 'severe form of trafficking' under section 103(8), Victims of Trafficking and Violence Protection Act of 2000, Pub. L No. 106-386.) See attached sheet. 2. The Victim's criminal involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) No criminal convictions. 3. Risk the Victim presents to public safety and/or to national security (Le., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary: (Attach copy of risk assessment report) No risk to public safety or national security 4. Financial responsibility for the Victim: (Please explain manner in which the Victim's living expenses will be met) 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state: attach additional sheet(s), if necessary.) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA00173743 6. Is employment authorization requested? Yes n No (II yes, please attach completed U.S. Citizenship and Immigration Services Forms 1-765, Application for Employment Authorization, and 1-102. Application for Replacement/Initial Nonimmigrant Arrival/Departure Document.) Note: Information contained in question #7 is not required for a victim to receive Continued Presence; however, this information is required for a victim to be certified to receive benefits from the Department of Health and Human Services (HHS), Office of Refugee Resettlement (ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. Is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. ill Yes K No Part E: Location where the Victim will reside (City and state are required at a minimum.) Street Address City Nco, Y c}z State 'Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for Continued Presence must be submitted to the ICE HSI Headquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reported to the requesting agency headquarters, which in turn will notify LEPU. The requesting agency will also notify LEPU immediately if the alien departs the United States. I Part F: Certification of Reporting Requirements As the requesting agency representative, I understand that, should this Continued Presence be granted, it is MY responsibility to follow all of the policies and procedures established by LEPU, including quarterly reporting, reporting changes in the Victim's status (i.e., departure or change in status), and requesting applicable extens ved Continued Presence. Date) Title) 1 / I td2 020 (Lead C ature) (Date) (Print Name and Title) If the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. —1 I (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 3 a' 4 EFTA00173744 Privacy Act Statement Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form will be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting law enforcement officer/agent and their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted under 5 U.S.C. § 552a(b) pursuant to the routine uses published in the Department of Homeland Security system of records notice, DNS/ICE-011 Immigration and Enforcement Operational Records. Disclosure: The disclosure of the information on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of the request for Continued Presence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4111) Page 4 of 4 EFTA00173745 FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE PART D:1 Jeffrey Epstein abused over several years, beginning when she was 18 years old. It was during the course of this abuse that Epstein brought into some of his massages to participate in sex acts with other girls. Epstein controlled every aspect of s life—including her physical appearance, her weight, and her clothing—for years. This controlling behavior took multiple abusive forms, including forcing to have multiple plastic surgeries, forcing her to engage in BDSM, referring to her as his "sex slave," insulting her, and physically abusing her, including by choking her and throwing her down a set of stairs. FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE EFTA00173746 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-102 OMB No. 1615-0079 Expires 10/31/2019 For USCIS Use Only Receipt Action Block New 1-94 Number Remarks ar. START HERE. Type or print in black ink Part 1. Information About You 1. Alien Registration Number (A-Number) la. A- 2. USCIS Online Account Number if any) I ri l l Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name I I I r U.S Mailing Address 4.a. In Care Of Name 4.b. Street Number and Name il 4.c. Apt. 2 Ste. 0 Fir. 0 4.d. 4.e. 5. U.S. Physical Address 6.a. In Care Of Name To Be Completed by an Attorney or Accredited Representative, if any. 0 Select this box if Form O-28 is attached to represent the applicant. Attorney State License Number 6.b. Street Number and Name 6.c. Apt. Ei Ste. 0 Fir. 6.d. City or Town 6.e. State 0 6.f. ZIP Code Other Information 7. Date of Birth (mm/dd/yyyy) ► 8. Count of Birth 9. Count of 'fizen hi 10. U.S. Social Security Number if an City or Town NEAN otkg Entry Information State NY 4.1. ZIP Code 11. Date of Last Entry into the United States Is your current U.S. mailing address the same as your (mm/dd/yyyy) ► U.S. physical address? 0 Yes 0 No If you answered "No" to Item Number 5., provide your 12. Place of Last Entry into the United States (City and State) LDS -AN 66 LES CA- U.S. physical address in Item Numbers 6.a. - 6.1. Form 1-102 10/19/17 N Page I of 4 EFTA00173747 Part 1. Information About You (continued) 13. Current Nonimmigrant Status 14. Date Status Expires (mm/dd/yyyy) ► 15.a. Form 1-94, I-94W, or 1-95 Arrival-D arture Record Number 1.b. USCIS Form Number and Name ► 15.b. Passport Number 2.a. Arc you now in removal proceedings? 0 Yes g No 15.e. Travel Document Number 2.b. If "Yes" complete Item Number 2.b. Provide detailed information regarding the proceedings. 154. Count of Issuance for Pass ort or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; 15.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. Part 3. Processing Information l.a. Arc you filing this application with any other petition or application? O Yes gj No If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number 1.b. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) l.a. O 1 am applying to replace my lost or stolen Form I-94 or I-94W. 1.b. O I am applying to replace my lost or stolen Form 1-95. 1.c. O I am applying to replace my Form 1-94 or I-94W because it was mutilated. I have attached my original Form 1-94 or I-94W. 1.d. 0 I am applying to replace my Form I-95 because it was mutilated. I have attached my original Form 1-95. g I was not issued Form 1-94 when I was admitted by CBP at a port-of-entry in the United States (whether at a land border, airport, or seaport). 11. O I was issued Form I-94,1-94W, or1-95 with incorrect information, and I am requesting that USCIS correct the document. I have attached my original Form 1-94, I-94W, or 1-95. 1.g. O I was not issued Form 1-94 when I entered as a nonimmigrant member of the military, and I am filing this application for an initial Form 1-94. 1.e. I\IG‘tv -PASS plepcitONI If you are unable to provide the original of your Form 1-94, I-94W, or 1-95, provide the following information: NOTE: Provide your name exactly as it appears on Form I-94, I-94W, or I-95. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. 5. Place of Last Entry into the United States (City and State) LDS ANhEI-65 CA Form 1-102 10/19/17 N Page 2 of 4 EFTA00173748 Part 4. Statement, Certification, Signature, and Contact Information of the Applicant NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. s] I can read and understand English, and have read and understand every question and instruction on this form, as well as my answer to every question. l.b. K The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above. 2. K I have requested the services of and consented to who is EI is not K an attorney or accredited representative, preparing this form for me. Applicant Certification I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immi ature 3.b. Date of Signature (mm/drYyyyy) ► Applicant's Contact Information 4. 5. 6. A licant's Da time Tel hone Number A licant's Mobile Tele hone Number E-mail A licant's Address --/N/24o Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) Lb. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. ID Ste. 0 FIr. O 3.c. City or Town 3.d. 3.f. 3.g. 3.h. State Province Postal Code Country 3.e. ZIP Code Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address Form I-102 10/19/17 N Page 3 of 4 EFTA00173749 Part 5. Contact Information, Certification, and Signature of the Interpreter (continued) Interpreter Certification I certify that: I am fluent in English and ,which is the same language provided in Part 4., Item Number 1.6.; I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number I.b.; and The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy) ► 1 Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name Provide the following information concerning the preparer: I.a. Pre Carers Famil Name Last Name) Lb. Pre ares Given Name First Name 2. Pre •arer's Business or Organization Namc Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. K Ste. It. City or Town Id. State Ntl 3.f. Province 3.g. Postal Code 3.b. Country 2lo PED62AL PLAZA Flr. K NEW yotk 3.e. ZIP Code 10278 UNIT-6Th SikreS Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. xi I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent. 7.b. K I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends K does not extend K beyond the preparation of this form. Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when required, supplied additional information to respond to a question on the form. 8.a. 8.b. Date of Signature d/yyyy) ► NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. Form 1-102 10/19/17 N Page 4 of 4 EFTA00173750 Application For Employment Authorization Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-765 OMB No. 1615-0040 Expires 05/31/2020 For USCIS Use Only • Authorization/Extension Fee Stamp Action Block Valid From K Authorization/Extension Valid Through Alien Registration Number A- , Remarks To be completed by an attorney or K Select this box if Form G-28 Attorney or Accredited Representative Board of Immigration Appeals (BIA)- accredited representative (if any). is attached. USCIS Online Account Number (if any) ► START HERE - Type or print in black ink. Part 1. Reason for Applying I am applying for (select only one box): 1.a. K Initial permission to accept employment. Lb. K Replacement of lost, stolen, or damaged employment authorization document, or correction of my employment authorization document NOT DUE to U.S. Citizenship and Immigration Services (USCIS) error. NOTE: Replacement (correction) of an employment authorization document due to USCIS error does not require a new Form 1-765 and filing fee. Refer to Replacement for Card Error in the What is the Filing Fee section of the Form I-765 Instructions for further details. K Renewal of my permission to accept employment. (Attach a copy of your previous employment authorization document.) 1.c. Part 2. Information About Yon Your Full Legal Name I.a. Family Name ■ (Last Name) Lb. Given Name (First Name) I.c. Middle Name Other Names Used Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 6. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Form 1-765 12/26/19 Page 1 of 7 EFTA00173751 Part 2. Information About You (continued) Your U.S. Mai!keg Address 5.a. In Care Of Name (if any) 5.b. Street Number and Name 5.c. 2 Apt. 0 Ste. 0 Flr. 5.d. City or Town 5.e. State Ny Nem Yock 5.1. ZIP Code 6. Is your current mailing address the same as your physical address? VI Yes 0 No NOTE: If you answered "No" to Item Number 6., provide your physical address below. U.S. Physical Address 7.a. Street Number and Name 7.b. 0 Apt. 0 Ste. 0 FIr. 7.c. City or Town 7.d. State Other 17.a. Family Name (Last Name) 17.b. Given Name (First Name) Information 8. Alien Registration Number (A-Number) (if any) ► A- Your Country or Countries of Citizenship or 9. USCIS Online Account Number (if any) Nationality List all countries where you are currently a citizen or national. If you need extra space to complete this item, use the space 10. Gender 0 Male Ii Female provided in Part 6. Additional Information. 11. Marital Status gs) Single 0 Married 0 Divorced K Widowed 18.a. Country 12. Have you previously filed Form I-765? 18.b. Country Oyes JNo 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ®Yes 0 No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you answered "Yes" to Item Number 13.a., provide the information requested in Item Number 13.b. 7.e. ZIP Code 13.6. Provide your Social Security number (SSN) (if known). 14. Do you want the SSA to issue you a Social Security card? (You must also answer "Yes" to Item Number 15., Consent for Disclosure, to receive a card.) 0 Yes ®No NOTE: If you answered "No" to Item Number 14., skip to Part 2., Item Number 18.a. If you answered "Yes" to Item Number 14., you must also answer "Yes" to Item Number 15. 15. Consent for Disclosure: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security card. 0 Yes 0 No NOTE: If you answered "Yes" to Item Numbers 14. - 15., provide the information requested in Item Numbers 16.a. - 17.b. Father's Name Provide your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mother's birth name. Fenn 1-765 12126/19 VIII IMINVIMMVISINIMENAIMIIIII Page 2 of 7 EFTA00173752 Part 2. Information About You (continued) Information About Your Eligibility Category 27. Eligibility Category. Refer to the Who May File Form Place of Birth I-765 section of the Form I-765 Instructions to determine List the city/town/village, state/province, and country where you were born. the appropriate eligibility category for this application. Enter the appropriate letter and number for your eligibility category below (for example, (aX8), (c)(17Xiii)). 19.a. Ci /Town/Vill e of Birth ( )( )( 1 28. (cX3XC) STEM OPT Eligibility Category. If you 19.b. State/Province of Birth entered the eligibility category (cX3XC) in Item Number 27., provide the information requested in Item Numbers 28.a - 28.e. 19.c. Country of Birth 28.a. Degree 28.b. Employers Name as Listed in E-Verify 20. Date of Birth (mm/dd/yyyy) Information About Your Last Arrival in the United States 21.a. Form 1-94 Arrival-Departure Record Number (if any) 21.b. Pass oR Number of Your Most Recent) Issued Pass ort 21.c. Travel Document Number (if any) 21.d. Coun That Issued Your Pass • •rt or Travel Document • 21.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 22. Date of Your Last Arrival Into the United States, On or About (mm/dd/yyyy) 23. Place of Your Last Arrival Into the United States LOS AMGELeS 24. Immigration Status at Your Last Arrival (for example, B-2 visitor. F-1 student, or no status) 25. Your Current Immigration Status or Category (for example, B-2 visitor, F- I student, parolee, deferred action, or no status or cate o ) 26. Student and Exchange Visitor Information System (SEWS) Number (if any) ► N- 28.c. Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number 29. (c)(26) Eligibility Category. If you entered the eligibility category (cX26) in Item Number 27., provide the receipt number of your H-1B spouse's most recent Form 1-797 Notice for Form 1-129, Petition for a Nonimmigrant Worker. ► 30. (cX8) Eligibility Category. If you entered the eligibility category (cX8) in Item Number 27., have you EVER been arrested for and/or convicted of any crime? Ei Yes 0 No NOTE: If you answered "Yes" to Item Number 30., refer to Special Filing Instructions for Those With Pending Asylum Applications (cX8) in the Required Documentation section of the Form 1-765 Instructions for information about providing court dispositions. 31.a. (eX35) and (eX36) Eligibility Category. If you entered the eligibility category (cX35) in Item Number 27., please provide the receipt number of your Form 1-797 Notice for Form 1-140, Immigrant Petition for Alien Worker. If you entered the eligibility category (cX36) in Item Number 27., please provide the receipt number of your spouse's or parent's Form 1-797 Notice for Form I-140. 31.b. If you ente ed the eligibility category (cX35) or (cX36) in Item Number 27., have you EVER been arrested for and/or convicted of any crime? 0 Yes 0 No NOTE: If you answered "Yes" to Item Number 31.b., refer to Employment-Based Nonimmigrant Categories, Items 8. - 9., in the Who May File Form I-765 section of the Form 1-765 Instructions for information about providing court dispositions. Form I-765 12/26/19 Eltriseminivimmentginvomal1/4•HII Page 3 of 7 EFTA00173753 Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form 1-765 Instructions before completing this section. You must file Form 1-765 while in the United States. Applicant's Statement NOTE: Select the box for either Item Number La. or I.b. If applicable, select the box for Item Number 2. 1.a. .12;1 I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. K The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in a language in which I am fluent, and I understood everything. 2. El At my request, the preparer named in Part 5., prepared this application for me based only upon information I provided or authorized. Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where neePcsary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Contact Information Applicant's Signature 3. Applicant's Daytime Telephone Number 7.a. A licant's Si nature S 4. Applicant's Mobile Telephone Number (if any) 7.b. Date of Signature (mm/dd/yyyy) oi./I412620 5. A licant's Email Address (if any) NOTE TO ALL APPLICANTS: If you do out this application or fail to submit required not completely fill documents listed in the Instructions, USCIS may deny your application. 6. El Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC settlement agreement. Part 4. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Form 1.765 12/26/19 rEnbliril;r5MtliaMtin rtti; III Page 4 of 7 EFTA00173754 Part 4. Interpreter's Contact Information, Certification, and Signature Interpreter's Mailing Address 3.a. Street Number and Name 3.b. O Apt. O Ste. 0 Flr. 3.c. City or Town 3.d. State 3.f. Province 3.g. Postal Code 3.h. Country 3.e. ZIP Code Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name l.a. Pre arers Famil N Lb. Pre arer's Given Name irst Name 2. Preparer's Business or Organization Name (if any) Fei Preparer's Mailing Address Interpreter's 3.a. Street Number and Name 3.b. O Apt. O Ste. I DEE-f\L PLAZIN Contact Information O Flr. 4. Interpreter's Daytime Telephone Number NEW YOIZW--- 3.c. City or Town 5. 3.d. State 3.e. ZIP Code Interpreter's Mobile Telephone Number (if any) NV 10276 3.1. Province 6. Interpreters Email Address (if any) 3.g. Postal Code 3.h. Country Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and which is the same language specified in Part 3., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy) N IT6 a SLAT-ES Preparer's Contact Information 4. Pre. arers Da ime Tele hone Number 5. Preparers Mobile Telephone Number (if any) 6. Pre arer's Email Address if an Form 1.765 12/26.119 IIIIIWYWRNTOOMINs1VM4 III 1%ire 5 (,:7 EFTA00173755 Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant (continued) 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. 7.b. K lam an attorney or accredited representative and my representation of the applicant in this case K extends K does not extend beyond the preparation of this application. NOTE: If you arc an attorney or accredited representative, you may need to 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, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature fi.a. Pr s S aturc 8.b. Date of Signature (m Form1-765 12/26/19 110 FeJOBRIMPOCMINEEMIIIII Page 6 of 7 EFTA00173756 Part 6. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) I.e. Middle Name 2. A-Number (if any) Ili. A- 3.a. Pa e Number 3.b. Part Number 3.c. Item Number 3.d. e Number 4.b. Part Number 4.c. Item Number 4.a. Pa 4.d. 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. 6.a. Pa e Number 6.b. Part Number 6.c. Item Number 6.d. 7.a. Pa c Number 7.b. Part Number 7.c. Item Number 7.d. Pam I-765 12/26/19 mememestavoramasenam Page 7 of 7 EFTA00173757 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Te1:1-800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJIS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Race: Date of Birth: NYFBINY0 0 Female Unknown NO NCIC WANT NAM) RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Federal NCIC WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJIS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Race: Date of Birth: Female Unknown EFTA00173758 NYFBINY00 NO NCIC PROTECTION ORDER FILE RECORD NANO RAC/U SEX/F Additional Inquiry Response OW: NYFBINY0U Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel:1-800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services OIII Information * The following information is provided in response to your request for a search of the III based on: Name: Sex: Female Race: Unknown Date of Birth: Purpose Code: NYFBINY00 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM) END SEX/F.RAC/U.PUR/C.ATN/MEDERK. EFTA00173759 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel:1-800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services 0 Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CRS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Race: Date of Birth: NYFBINY 0 0 Female Unknown NO NCIC WANT RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Te1:1-800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJIS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC EFTA00173760 restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Race: Date of Birth: NYFBINY0 0 Female Unknown NO NCIC PROTECTION ORDER FILE RECORD NAM RAC/U SEX/F Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel:l-800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *III Information * The following information is provided in response to your request for a search of the III based on: Name: Sex: Race: Date of Birth: Female Unknown Purpose Code: NYFBINY0 0 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM SEX/ F . RAC /U . PUR/C . ATN/MEDERK . END EFTA00173761