Part 10. Signature. After reading the in<strong>f<strong>or</strong></strong>mation on penalties in the instructions, complete and sign below. If someone helped you prepare this application, he <strong>or</strong> she must complete Part 11. I certify, under penalty <strong>of</strong> perjury under the laws <strong>of</strong> the United States <strong>of</strong> America, that this application and the evidence submitted with it are all true and c<strong>or</strong>rect. Title 18, United States Code, Section 1546, provides in part: "Whoever knowingly makes under oath, <strong>or</strong> as permitted under penalty <strong>of</strong> perjury under Section 1746 <strong>of</strong> Title 28, United States Code, knowingly subscribes as true, any false statement with respect to a material fact in any application, affidavit, <strong>or</strong> other document required by the immigration laws <strong>or</strong> regulations prescribed thereunder, <strong>or</strong> knowingly presents any such application, affidavit, <strong>or</strong> other document containing any such false in<strong>f<strong>or</strong></strong>mation <strong>or</strong> which fails to contain any reasonable basis in law <strong>or</strong> fact shall be fined in acc<strong>or</strong>dance with this title <strong>or</strong> imprisoned not m<strong>or</strong>e than five years, <strong>or</strong> both." Staple photographs here I auth<strong>or</strong>ize the release <strong>of</strong> any in<strong>f<strong>or</strong></strong>mation from my rec<strong>or</strong>d that the Bureau <strong>of</strong> Citizenship and Immigration Services needs to determine eligibility <strong>f<strong>or</strong></strong> the benefit I am seeking. WARNING: Applicants who are in the United States illegally are subject to dep<strong>or</strong>tation <strong>or</strong> removal if their applications are not granted by an Asylum Officer <strong>or</strong> an Immigration Judge. Any in<strong>f<strong>or</strong></strong>mation provided in completing this application may be used as a basis <strong>f<strong>or</strong></strong> the institution <strong>of</strong>, <strong>or</strong> as evidence in, dep<strong>or</strong>tation <strong>or</strong> removal proceedings, even if the application is later withdrawn. Signature <strong>of</strong> Applicant: Print Name: Date: Write your name in your native alphabet: (Month/Day/Year) Part 11. Signature <strong>of</strong> person preparing <strong>f<strong>or</strong></strong>m, if other than above. (Read the following in<strong>f<strong>or</strong></strong>mation and sign below.) I declare that I have prepared this application at the request <strong>of</strong> the person named in Part 10, that the responses provided are based on all in<strong>f<strong>or</strong></strong>mation <strong>of</strong> which I have knowledge, <strong>or</strong> which was provided to me by the applicant, and that the completed application was read to the applicant in a language the applicant speaks fluently <strong>f<strong>or</strong></strong> verification be<strong>f<strong>or</strong></strong>e he <strong>or</strong> she signed the application in my presence. I am aware that the knowing placement <strong>of</strong> false in<strong>f<strong>or</strong></strong>mation on the F<strong>or</strong>m I-<strong>881</strong> may subject me to civil penalties under 8 U.S.C. 1324 (c). Signature <strong>of</strong> Preparer: Print Name: Date: Daytime Telephone #: Address <strong>of</strong> Preparer: (Street # and Name, City <strong>or</strong> Town, State, Zip Code) ( ) Part 12. To be completed at interview <strong>or</strong> hearing. You will be asked to complete this Part when you are be<strong>f<strong>or</strong></strong>e an Asylum Officer <strong>of</strong> the Bureau <strong>of</strong> Citizenship and Immigration Services <strong>or</strong> an Immigration Judge <strong>of</strong> the Executive Office <strong>f<strong>or</strong></strong> Immigration Review (EOIR) <strong>f<strong>or</strong></strong> examination. I swear (affirm) that I know the contents <strong>of</strong> this application that I am signing, including the attached documents and supplements, are all true <strong>or</strong> not all true to the best <strong>of</strong> my knowledge and that the c<strong>or</strong>rections numbered to were made by me <strong>or</strong> at my request. Signed and sw<strong>or</strong>n to be<strong>f<strong>or</strong></strong>e me by the above-named applicant on: Signature <strong>of</strong> Applicant Date (Month/Day/Year) Write your Name in your Native Alphabet Signature <strong>of</strong> Asylum Officer <strong>or</strong> Immigration Judge F<strong>or</strong>m I-<strong>881</strong> (Rev. 04/16/04) N (Pri<strong>or</strong> versions may be used until 09/30/04) Page 7
NOTE: Use this blank sheet to supplement any in<strong>f<strong>or</strong></strong>mation requested. Please copy and submit as needed. A# Print Name Signature <strong>of</strong> Applicant: Part Question Date: (mm/dd/yyyy) F<strong>or</strong>m I-<strong>881</strong> (Rev. 04/16/04) N (Pri<strong>or</strong> versions may be used until 09/30/04) Page 8
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