Form I-130A 02/13/19 Page 1 of 6 USCIS Form I-130A OMB No. 1615-0012 Expires 02/28/2021 To be completed by an attorney or accredited representative (if any). START HERE - Type or print in black ink. Part 1. Information About You (Spouse Beneficiary)4.c.4.f.4.h.4.g.4.d.4.a.4.b.Street Number and Name Apt. Ste. Flr. City or Town State 4.e. ZIP Code Province Country Postal Code Physical Address 1 Address HistoryProvide your physical addresses for the last five years, whether inside or outside the United States.240 Provide your current address first.240 If you need extra space to complete this section, use the space provided in Part 7. Additional Information.6.c.6.f.6.h.6.g.6.d.6.a.6.b.Street Number and Name Apt. Ste. Flr. City or Town State 6.e. ZIP Code Province Country Postal Code Physical Address 2 Select this box if Form G-28 is attached.Attorney State Bar Number (if applicable)Attorney or Accredited Representative USCIS Online Account Number (if any) Date From (mm/dd/yyyy)7.a.Date To (mm/dd/yyyy)7.b. Family Name (Last Name) Given Name (First Name) Middle Name Your Full Name3.c. 3.b. 3.a.1.Alien Registration Number (A-Number) (if any)A-USCIS Online Account Number (if any)2. Date From (mm/dd/yyyy)5.a.Date To (mm/dd/yyyy)5.b. Postal Code Country Province City or Town Apt. Ste. Flr. Street Number and Name8.b.8.a.8.e.8.f.8.d.8.c.Provide your last address outside the United States of more than one year (even if listed above). The purpose of this form is to collect additional information for a spouse beneficiary of Form I-130, Petition for Alien Relative. If your spouse is a U.S. citizen, lawful permanent resident, or non-citizen U.S. national who is filing Form I-130 on your behalf, you must complete and sign Form I-130A, Supplemental Information for Spouse Beneficiary, and submit it with the Form I-130 filed by your spouse. If you reside overseas, you still must complete Form I-130A, but you do not need to sign the form. Volag Number (if any) Last Physical Address Outside the United StatesSupplemental Information for Spouse Beneficiary Department of Homeland Security U.S. Citizenship and Immigration Services American LegalNet, Inc. www.FormsWorkFlow.com Form I-130A 02/13/19 Page 2 of 6 9.b.Date To (mm/dd/yyyy)9.a.Date From (mm/dd/yyyy) Part 1. Information About You (The Spouse Beneficiary)Full Name of Parent 1 Information About Parent 1Given Name (First Name) Middle Name 13.City/Town/Village of Birth 14. 16.Country of Residence City/Town/Village of Residence15.Country of Birth 11.Date of Birth (mm/dd/yyyy) Family Name (Maiden Name) Part 2. Information About Your Employment Provide your employment history for the last five years, whether inside or outside the United States.240 Provide your current employment first.240 If you are currently unemployed, type or print "Unemployed" in Item Number 1. below. If you need extra space to complete this section, use the space provided in Part 7. Additional Information. Employment HistoryCity or Town2.c.2.f.2.h.ProvinceCountry 2.g.Postal Code ZIP Code2.e.State2.d.Street Number and Name2.a. 2.b. Apt. Ste. Flr. Employer 11.Name of Employer/Company Date of Birth (mm/dd/yyyy)18. Country of Birth 22.City/Town/Village of Residence Country of Residence23. 21. City/Town/Village of Birth 20. Middle Name Given Name (First Name) Information About Parent 217.a.Full Name of Parent 2Family Name (Last Name) 3.Your Occupation Date From (mm/dd/yyyy)4.a.Date To (mm/dd/yyyy)4.b. City or Town6.c.6.f.6.h.ProvinceCountry 6.g.Postal Code ZIP Code6.e.State6.d.Street Number and Name6.a. 6.b. Apt. Ste. Flr. Employer 25.Name of Employer/Company 10.a.10.b.10.c.17.b.17.c.12.Sex Male Female19.Sex Male Female American LegalNet, Inc. www.FormsWorkFlow.com Form I-130A 02/13/19 Page 3 of 6 Part 2. Information About Your Employment (continued)7.Your Occupation 3.Provide your last occupation outside the United States if not shown above.240 If you never worked outside the United States, provide this information in the space provided in Part 7. Additional Information.Your Occupation 1.Name of Employer/Company Date From (mm/dd/yyyy)8.a.Date To (mm/dd/yyyy)8.b. Date From (mm/dd/yyyy)4.a.Date To (mm/dd/yyyy)4.b. Part 3. Information About Your Employment Outside the United StatesThe interpreter named in Part 5. read to me every question and instruction on this form and my answer to every question in 1.b. a language in which I am fluent, and I understood everything., 2. At my request, the preparer name in Part 6.,prepared this form for me based only upon information I provided or authorized.,Spouse Beneficiary's Daytime Telephone Number3. Spouse Beneficiary's Contact Information Spouse Beneficiary's Email Address (if any)5.Spouse Beneficiary's Mobile Telephone Number (if any) 4. Spouse Beneficiary's CertificationCopies 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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.I further 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 and enforcement of U.S. immigration laws.City or Town2.c.2.f.2.h.ProvinceCountry 2.g.Postal Code ZIP Code2.e.State2.d.Street Number and Name2.a. 2.b. Apt. Ste. Flr. I can read and understand English, and I have read and understand every question and instruction on this form and my answer to every question. 1.a.NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. Part 4. Spouse Beneficiary's Statement, Contact Information, Certification, and Signature Spouse Beneficiary's StatementNOTE: Read the Penalties section of the Form I-130 and Form I-130A Instructions before completing this part.I certify, under penalty of perjury, that I provided or authorized all of the information in this form, I understand all of the information contained in, and submitted with, my form, and that all of this information is complete, true, and correct. Spouse Beneficiary's Signature Date of Signature (mm/dd/yyyy)6.b. Spouse Beneficiary's Signature (sign in ink)6.a.NOTE TO ALL SPOUSE BENEFICIARIES: If you do not completely fill out this form or fail to submit required documents listed in the Instructions, USCIS may deny the Form I-130 filed on your behalf. American LegalNet, Inc. www.FormsWorkFlow.com Form I-130A 02/13/19 Page 4 of 6 Interpreter's Business or Organization Name (if any)2. Interpreter's Given Name (First Name)1.b. Interpreter's Family Name (Last Name)1.a. Interpreter's Full Name Part 5. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter you used to complete Form I-130A if he or she is different from the interpreter used to complete the Form I-130 filed on your behalf. Interpreter's Mailing Address3.c.City or Town3.d.State3.e.ZIP Code3.f.Postal CodeStreet Number and Name3.a. 3.b. Apt. Ste. Flr. 3.g.3.h.Country Province Interpreter's Certification I am fluent in English and which is the same language provided in Part 4., Item Number 1.b., and I have read to this spouse beneficiary in the identified language every question and instruction on this form and his or her answer to every question. The spouse beneficiary informed me that he or she understands every instruction, question, and answer on the form, including the Spouse Beneficiary's Certification, and has verified the accuracy of every answer.I certify, under penalty of perjury, that:, Interpreter's Signature Date of Signature (mm/dd/yyyy)7.b.Interpreter's Signature (sign in ink)7.a. Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Form, if Other Than the Spouse BeneficiaryProvide the following information about the preparer you used to complete Form I-130A if he or she is different from the preparer used to complete the Form I-130 filed on your behalf.Preparer's Given Name (First Name)1.b. 2.Preparer's Busi