Professional Documents
Culture Documents
USCIS
Form I-131A
OMB No. 1615-0135
Expires 08/31/2018
Action Block
Receipt
For
USCIS
Document Issued
Use
Transportation Letter
Only
Boarding Foil
Date:
(mm/dd/yyyy)
To be completed by an
attorney or accredited
representative (if any).
4.
2.
5.b.
Apt.
Ste.
Flr.
Other Information
6.
Apt.
Ste.
Flr.
7.
3.f.
3.g. Province
3.h. Postal Code
3.i.
ZIP Code
9.
10.
Sex
Male
Female
Country
Page 1 of 5
11.
Country of Birth
12.
1.b.
1.c.
1.d.
1.e.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.a.
1.b.
2.
3.
2.
,
prepared this application for me based only upon
information I provided or authorized.
No
3.
4.
5.
No
Applicant's 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 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 necessary for the
administration and enforcement of U.S. immigration laws.
Page 2 of 5
Apt.
Ste.
Flr.
Province
5.
6.
Applicant's Signature
6.a. Applicant's Signature
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
Interpreter's Signature
1.b. Interpreter's Given Name (First Name)
2.
Page 3 of 5
Preparer's Statement
7.a.
7.b.
2.
Apt.
Ste.
Flr.
Province
Preparer's Signature
8.a. Preparer's Signature
5.
6.
Page 4 of 5
5.d.
A-
A-Number
3.d.
7.d.
4.d.
Page 5 of 5