Ina 103a

Form I-130A

I absolutely LOVE my 2012 Streetglide, but even with an aftermarket header (V&H powerduals), free flowing airfilter, and a race tuner, it still doesn't do it for me. Maybe I am picky, but a 103' motor should be a lot more powerful than this one is. I blame lower compresson, and sissified cam. Part 43 - Contract Modifications 43.000 Scope of part. Contract modifications are of the following types: (a) Bilateral. A bilateral modification (supplemental agreement) is a contract modification that is signed by the contractor and the contracting officer.

USCIS
OMB No. 1615-0012
To be completed by an attorney or accredited representative (if any).
Part 1. Information About You (Spouse

Official Form 103A Application for Individuals to Pay the Filing Fee in Installments Official Form 103A Application for Individuals to Pay the Filing Fee in Installments 12/15 Be as complete and accurate as possible. If two married people are filing together, both are equally responsible for.

4.c.
4.h.
4.d.
4.b.
and Name
City or Town
Province
Postal Code
Address History
Provide your physical addresses for the last five years, whether
inside or outside the United States. Provide your current
address first. If you need extra space to complete this section,
use the space provided in Part 7. Additional Information.
6.f.
6.g.
6.a.
Street Number
Apt.Ste.Flr.
State6.e. ZIP Code
Country
Physical Address 2
Form G-28 is
Attorney State Bar Number
Attorney or Accredited Representative
Date From (mm/dd/yyyy)7.a.
Family Name
Given Name
Middle Name
3.c.
3.a.
A-
Date From (mm/dd/yyyy)5.a.
Postal Code
Province
Apt.Ste.Flr.
and Name
8.a.
8.f.
8.c.
Provide your last address outside the United States of more than
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.
(if any)
Supplemental Information for Spouse Beneficiary
U.S. Citizenship and Immigration Services
9.b.Date To (mm/dd/yyyy)
Part 1. Information About You (The Spouse
Full Name of Parent 1
Given Name
Middle Name
ofBirth
16.Country of Residence
Country of Birth
Family Name
Part 2. Information About Your Employment
Provide your employment history for the last five years,
whether inside or outside the United States. Provide your
current employment first. 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
Employment History
2.f.
Province
2.g.Postal Code
Street Number
2.a.
Employer 1
Date of Birth (mm/dd/yyyy)18.
22.City/Town/Village of Residence
21.
ofBirth
Middle Name
(First Name)
17.a.
Family Name
3.Your Occupation
Date To (mm/dd/yyyy)4.b.
6.f.
Province
6.g.Postal Code
Street Number
6.a.
Employer 2
10.a.
10.c.
17.c.
MaleFemale
MaleFemale
Part 2. Information About Your Employment
7.Your Occupation
Provide your last occupation outside the United States if not
shown above. If you never worked outside the United States,
provide this information in the space provided in Part 7.
Your Occupation
Date From (mm/dd/yyyy)8.a.
Date From (mm/dd/yyyy)4.a.
Part 3. Information About Your Employment
The interpreter named in Part 5. read to me every
question and instruction on this form and my answer
1.b.
a language in which I am fluent, and I understood
,
prepared this form for me based only upon
,
Spouse Beneficiary's Contact Information
Spouse Beneficiary's Mobile Telephone Number (if any)4.
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 of my records that USCIS may need to determine my
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
City or Town2.c.
2.h.
Country
ZIP Code2.e.State2.d.
and Name
2.b.Apt.Ste.Flr.

Ina 103 A 3

I can read and understand English, and I have read
and understand every question and instruction on this
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
Part 4. Spouse Beneficiary's Statement, Contact
Spouse Beneficiary's Statement
NOTE: Read thePenalties 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.
Date of Signature (mm/dd/yyyy)6.b.
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
Interpreter's Business or Organization Name (if any)2.
Interpreter's Family Name (Last Name)1.a.
Part 5. Interpreter's Contact Information,
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.
3.c.City or Town
3.f.
103a
Street Number
3.a.
3.g.
Province
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.
,
Date of Signature (mm/dd/yyyy)7.b.
Part 6. Contact Information, Declaration, and
Other Than the Spouse Beneficiary
Provide 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.
2.Preparer's Business or Organization Name (if any)
1.a.Preparer's Family Name (Last Name)
Interpreter's Daytime Telephone Number4.
Interpreter's Mobile Telephone Number (if any)5.
3.c.City or Town
3.f.
Street Number
3.a.
3.g.
Province
Part 6. Contact Information, Declaration, and
Other Than the Spouse Beneficiary(continued)
Preparer's Mobile Telephone Number (if any)5.
Preparer's Email Address (if any)6.
I am not an attorney or accredited representative but
beneficiary and with the spouse beneficiary's consent.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this form, you may be obliged to submit
Appearance as Attorney or Accredited Representative,
I am an attorney or accredited representative and my
representation of the spouse beneficiary in this case
7.b.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this form at the request of the spouse beneficiary. The
spouse beneficiary then reviewed this completed form and
informed me that he or she understands all of the information
contained in, and submitted with, his or her form, including the
Spouse Beneficiary's Certification, and that all of this
information is complete, true, and correct. I completed this

Ina 10386 Esd Sensitive

form based only on information that the spouse beneficiary
Preparer's Signature
8.b.Date of Signature (mm/dd/yyyy)
Part 7. Additional Information
If you need extra space to provide any additional information
within this form, 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 form 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
A-Number (if any)
3.a.
Page Number3.b.Part Number3.c.Item Number
Page Number
Page NumberPart NumberItem Number5.a.
5.b.
5.c.
5.d.
1.c.
(Last Name)
(First Name)
4.c.4.b.
4.a.
6.c.6.b.6.a.
7.d.

James C. Tai, Esq.


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