Part 5: Preparer's Info
If no preparer assisted with this petition, you may leave this page blank.
Preparer's Full Name
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Please enter the preparer's family name.
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Please enter the preparer's given name.
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Preparer's Mailing Address
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Street address is required.
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City is required.
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State is required.
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Country is required.
Preparer's Contact Information
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Please enter the preparer's daytime phone number.
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Please enter a valid email address.
Preparer's Statement
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Please select a preparer status.
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Please select the representation scope.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28 with this application.
Preparer Sign Below
NOTE: Use your finger or mouse to draw your signature.
Leave it blank if you prefer to sign the PDF on paper or digitally later.
Leave it blank if you prefer to sign the PDF on paper or digitally later.