Sponsor's Notice of Change of Address Department of Homeland Security U.S. Citizenship and Immigration Services Returned For USCIS Use Only Resubmitted Remarks USCIS Form I-865 Action Block Date (mm/dd/yyyy) Date (mm/dd/yyyy) Date (mm/dd/yyyy) Date (mm/dd/yyyy) CSID Number: START HERE - Type or print in black ink. Part 1. Information About You (Sponsor) Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Your New Mailing Address 6.a. In Care Of Name (if any) 6.b. Street Number and Name 6.c. Apt. Ste. Flr. 6.d. City or Town Other Information 2. Date of Birth (mm/dd/yyyy) 6.e. State 6.g. Province 6.h. Postal Code 6.i. Country 6.f. ZIP Code Your New Physical Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 7. 3.c. City or Town 3.d. State 3.f. Province 3.e. ZIP Code Effective Date of Change of Address (mm/dd/yyyy) Part 2. Information About the Sponsored Immigrants Provide the requested information on the persons you are sponsoring. Sponsored Immigrant 1 3.g. Postal Code 3.h. Country 4. Effective Date of Change of Address (mm/dd/yyyy) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) No 1.c. Middle Name 2. Alien Registration Number (A-Number) (if any) A- 5. Is your new physical address the same as your new mailing address? Yes If you answered "No" to Item Number 5., provide your new mailing address in Item Numbers 6.a. - 7. Form I-865 07/17/15 N Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Information About the Sponsored Immigrants (continued) Sponsored Immigrant 2 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 1.b. The interpreter named in Part 4. has also read to me every question and instruction on this notice, as well as my answer to every question, in , a language in which I am fluent. I understand every question and instruction on this notice as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. 2. 4. A-Number (if any) A- I have requested the services of and consented to , who is is not an attorney or a accredited representative, preparing this notice for me. Sponsored Immigrant 3 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 6. A-Number (if any) A- Sponsor's Contact Information 3. Sponsor's Daytime Telephone Number 4. Sponsor's Mobile Telephone Number (if any) 5. Sponsor's Email Address (if any) Sponsored Immigrant 4 7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Middle Name 8. A-Number (if any) A- Sponsor'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 that I seek. I furthermore authorize release of information contained in this notice, 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. I certify, under penalty of perjury, that the information in my notice and any document submitted with my notice were provided by me and are complete, true, and correct. NOTE: If you are sponsoring more than four persons, use the space provided in Part 6. Additional Information to provide the information requested for each additional individual. Part 3. Sponsor's Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-865 Instructions before completing this part. Sponsor's Signature 6.a. Sponsor's Signature Sponsor'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. I can read and understand English, and have read and understand every question and instruction on this notice, as well as my answer to every question. 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL SPONSORS: If you do not completely fill out this notice or fail to submit required documents listed in the Instructions, USCIS may reject your notice. Form I-865 07/17/15 N Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Signature 6.a. Interpreter's Signature Interpreter's Full Name 1.a. Interpreter's Family Name (Last Name) 6.b. Date of Signature (mm/dd/yyyy) 1.b. Interpreter's Given Name (First Name) Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this Notice, If Other Than the Sponsor Provide the following information about the preparer. 2. Interpreter's Business or Organization Name (if any) Preparer's Full Name Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 2. 3.e. ZIP Code Preparer's Business or Organization Name (if any) 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 3.c. City or Town 3.d. State 3.f. Province Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.g. Postal Code 3.h. Country 3.c. City or Town Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 3.d. State 3.f. Province 3.e. ZIP Code 5. Interpreter's Email Address (if any) 3.g. Postal Code 3.h. Country Interpreter's Certification I certify that: I am fluent in English and , which is the same language provided in Part 3., Item Number 1.b.; 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 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. Form I-865 07/17/15 N Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's Email Address (if any) Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this Notice, If Other Than the Sponsor (continued) Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this notice on beha