Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0047
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes)
Your employer is required to verify your documents and complete section 2 of this form. Is your employer present?
Please Select the Appropriate Document List(s)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
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