| --- |
| title: "DOJ Epstein Files, Data Set 10 (EFTA01263124)" |
| source: "DOJ Epstein Files, Data Set 10" |
| sourceUrl: "https://huggingface.co/datasets/ishumilin/epstein-files-ocr-complete" |
| date: "2026-01-01" |
| category: "DOJ Data Set" |
| eftaNumber: "EFTA01263124" |
| ocrPages: 0 |
| ocrChars: 45611 |
| ocrElapsed: 0.0 |
| parseTier: "external" |
| engine: "ishumilin OCR pipeline (engine undisclosed; CC0 mirror)" |
| externalSource: "ishumilin-ocr-complete" |
| externalLicense: "CC0-1.0" |
| externalCredit: "ishumilin/epstein-files-ocr-complete (Hugging Face)" |
| externalUrl: "https://huggingface.co/datasets/ishumilin/epstein-files-ocr-complete" |
| --- |
| |
| THE UNITED STATES OF AMERICA |
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| ## CERTIFICATE OF |
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| No. 27564548 |
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| Personal description of holder as of date of naturalization: |
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| NATURALIZATION |
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| Date of birth |
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| ```markdown |
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| Sex: FEMALE |
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| ``` |
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| Height. 5 feet 8 inches |
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| Country of former nationality: FRANCE |
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| Marital status: SINGLE |
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| ```markdown |
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| INS Registration No. |
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| ``` |
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| Chiara Nobile Marwell |
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| (complete and true signature of holder) |
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| I certify that the description given is true, and that the photograph affixed hereto is a likeness of me. |
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| Be it known that, pursuant to an application filed with the Attorney General |
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| at: ST. THOMAS, VIRGIN ISLANDS |
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| The Attorney General having found that: |
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| GHISLAINE NOELLE MAXWELL |
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| then residing in the United States, intends to reside in the United States when so required by the Naturalization Laws of the United States, and had in all other respects complied with the applicable provisions of such naturalization laws and was entitled to be admitted to citizenship, such person having taken the oath of allegiance in a ceremony conducted by the |
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| US INS CHARLOTTE AMALIE ST. THOMAS USVI |
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| at: ST. THOMAS, VIRGIN ISLANDS |
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| on: NOV 27 2002 |
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| IT IS PUNISHABLE BY U. S. LAW TO COPY, PRINT OR PHOTOGRAPH THIS CERTIFICATE, WITHOUT LAWFUL AUTHORITY. |
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| that such person is admitted as a citizen of the United States of America. |
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| Commissioner of Immigration and Naturalization |
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| DEPARTMENT OF JUSTICE |
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| FORM N-550 REV. 6-91 |
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| ```markdown |
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| ``` |
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| EFTA_00114802 |
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| EFTA01263124 |
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| U.S. Department of Justice |
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| Immigration and Naturalization Service |
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| UMB No. 1115-0309 |
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| Application for Naturalization |
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| Print clearly or type your answers using CAPITAL letters. Failure to print clearly may delay your application. Use black or blue ink. |
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| ## Part 1. Your Name (The Person Applying for Naturalization) |
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| ## A Your current legal name. |
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| <table border="1"><tr><td colspan="2">Maxwell</td></tr><tr><td>Given Name(First Name)</td><td>Full Middle Name(If applicable)</td></tr><tr><td>Ghialaine</td><td>NOELLE</td></tr></table> |
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| ## B. Your name exactly as it appears on your Permanent Resident Card. |
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| <table border="1"><tr><td colspan="2">Family Name (Last Name)</td></tr><tr><td colspan="2">Maxwell</td></tr><tr><td>Given Name(First Name)</td><td>Full Middle Name(If applicable)</td></tr><tr><td>Ghislaine</td><td>N.</td></tr></table> |
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| C. If you have ever used other names, provide them below. |
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| <table border="1"><tr><td>Family Name(Last Name)</td><td>Given Name(First Name)</td><td>Middle Name</td></tr><tr><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td></tr></table> |
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| ## D. Name change (*optional*) |
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| Please read the Instructions before you decide whether to change your name. |
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| T. Would you like to legally change your name? |
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| 2. If "Yes," print the new name you would like to use. Do not use initials or abbreviations when writing your new name. |
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| Family Name (Last Name) |
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| <table border="1"><tr><td>Given Name(First Name)</td><td>Full Middle Name</td></tr><tr><td></td><td></td></tr></table> |
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| ## Part 2. Information About Your Eligibility (Check Only One) |
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| ## FOR INSURE ONLY |
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| 1 am at least 18 years old AND |
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| APPROVED |
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| SAJ DISTRICT DIRECTOR |
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| AUG 29 2002 |
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| A. I have been a Lawful Permanent Resident of the United States for at least 5 years. |
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| C. $ \Box $ 1 am applying on the basis of qualifying military service. |
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| D. Other (Please explain) |
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| B. $ \Box $ I have been a Lawful Permanent Resident of the United States for at least 3 years, AND I have been married to and living with the same U.S. citizen for the last 3 years, AND my spouse has been a U.S. citizen for the last 3 years. |
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| negative IB1S |
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| Sa 11-26-02 negative IB1S |
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| Sa 8-29-02 |
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| ```markdown |
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| SDNY_NGM[000600719(01)]N |
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| ``` |
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| EFTA_00114803 |
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| EFTA01263125 |
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| |
| |
| |
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| ```markdown |
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| [SDNY_LGMR600007201]N Page 2 |
| ``` |
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| EFTA_00114804 |
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| EFTA01263126 |
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| Part 6. Information About Your Residence and Employment |
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| A. Where have you lived during the last 5 years? Begin with where you live now and then list every place you lived for the last 5 years. If you need more space, use a separate sheet of paper. |
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| B. Where have you worked (or, if you were a student, what schools did you attend) during the last 5 years? Include military service. Begin with your current or latest employer and then list every place you have worked or studied for the last 5 years. If you need more space, use a separate sheet of paper. |
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| <table><thead><tr><th rowspan="2">Employer or School Name</th><th rowspan="2">Employer or School Address (Street, City and State)</th><th colspan="2">Dates (Month/Year)</th><th rowspan="2">Your Occupation</th></tr><tr><th>From</th><th>To</th></tr></thead><tbody><tr><td>L.S.J., LLC</td><td>6100 Red Hk, St. Thom., USVI</td><td>0 8 2 7 0 1</td><td>Present</td><td>Manager</td></tr><tr><td>NES, LLC</td><td>457 Madison Ave., NY, NY</td><td>0 1 / 2 0 0 1</td><td>0 8 2 4 0 1</td><td>Manager</td></tr><tr><td>J. Epstein & Co.</td><td>457 Madison Ave., NY, NY</td><td>0 1 / 1 9 9 3</td><td>1 2 / 2 0 0 0</td><td>Manager</td></tr><tr><td></td><td></td><td>--- / ---</td><td>--- / ---</td><td></td></tr><tr><td></td><td></td><td>--- / ---</td><td>--- / ---</td><td></td></tr></tbody></table> |
|
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| Form N-400 (Rev. 05/31/01)N Page 3 |
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| ```markdown |
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| SDNY_GM_00000721 |
| ``` |
|
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| EFTA_00114805 |
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| EFTA01263127 |
| |
| B. How many trips of 24 hours or more have you taken outside of the United States during the past 5 years? |
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| C. List below all the trips of 24 hours or more that you have taken outside of the United States since becoming a Lawful Permanent Resident. Begin with your most recent trip. If you need more space, use a separate sheet of paper. See on attachment |
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| <table border="1"><tr><td>Date You Left the United States(Month/Day/Year)</td><td>Date You Returned to the United States(Month/Day/Year)</td><td colspan="2">Did Trip Last6 Months orMore?</td><td>Countries to Which You Traveled</td><td>Total DaysOut of theUnited States</td></tr><tr><td>11/18/2001</td><td>11/26/2001</td><td>□Yes</td><td>No</td><td>France, Italy, United Kingdom</td><td>8</td></tr><tr><td>09/21/2001</td><td>10/01/2001</td><td>□Yes</td><td>No</td><td>France, Italy, United Kingdom</td><td>10</td></tr><tr><td>07/19/2001</td><td>08/01/2001</td><td>□Yes</td><td>No</td><td>United Kingdom, France</td><td>12</td></tr><tr><td>06/22/2001</td><td>06/29/2001</td><td>□Yes</td><td>No</td><td>France</td><td>7</td></tr><tr><td>05/17/2001</td><td>05/20/2001</td><td>□Yes</td><td>No</td><td>Canada</td><td>3</td></tr><tr><td>03/05/2001</td><td>03/11/2001</td><td>□Yes</td><td>No</td><td>France, United Kingdom</td><td>6</td></tr><tr><td>12/04/2000</td><td>12/09/2000</td><td>□Yes</td><td>No</td><td>France, United Kingdom</td><td>5</td></tr><tr><td>10/25/2000</td><td>10/29/2000</td><td>□Yes</td><td>No</td><td>United Kingdom</td><td>4</td></tr><tr><td>08/31/2000</td><td>09/04/2000</td><td>□Yes</td><td>No</td><td>United Kingdom</td><td>4</td></tr><tr><td>07/05/2000</td><td>07/17/2000</td><td>□Yes</td><td>No</td><td>France, United Kingdom</td><td>12</td></tr></table> |
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| ## Part 8. Information About Your Marital History |
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| A. How many times have you been married (including annulled marriages)? If you have NEVER been married, go to Part 9. |
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| B. If you are now married, give the following information about your spouse: |
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| ```markdown |
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| SDNY_GM_00000722 |
| Form N-400{Rev: 05/31/01}N Page 4 |
| ``` |
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| EFTA_00114806 |
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| EFTA01263128 |
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|
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| EFTA_00114807 |
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| EFTA01263129 |
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| Part 9. Information About Your Children |
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| Write your INS "A" - number here: |
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| A. How many sons and daughters have you had? For more information on which sons and daughters you should include and how to complete this section, see the Instructions. |
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| B. Provide the following information about all of your sons and daughters. If you need more space, use a separate sheet of paper. |
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| <table><thead><tr><th>Full Name of Son or Daughter</th><th>Date of Birth (Month/Day/Year)</th><th>INS "A" number (if child has one)</th><th>Country of Birth</th><th>Current Address (Street, City, State & Country)</th></tr></thead><tbody><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr><tr><td></td><td>___/___/___</td><td>A___</td><td></td><td></td></tr></tbody></table> |
|
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| ## Part 10. Additional Questions |
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| Please answer questions 1 through 14. If you answer "Yes" to any of these questions, include a written explanation with this form. Your written explanation should (1) explain why your answer was "Yes," and (2) provide any additional information that helps to explain your answer. |
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| ## A. General Questions |
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| 1. Have you EVER claimed to be a U.S. citizen (in writing or any other way)? |
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| 2. Have you EVER registered to vote in any Federal, state, or local election in the United States? |
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| 3. Have you EVER voted in any Federal, state, or local election in the United States? |
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| 4. Since becoming a Lawful Permanent Resident, have you EVER failed to file a required Federal, state, or local tax return? |
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| 5. Do you owe any Federal, state, or local taxes that are overdue? |
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| 6. Do you have any title of nobility in any foreign country? |
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| 7. Have you ever been declared legally incompetent or been confined to a mental institution within the last 5 years? |
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| Form N.400 (Rev. 05/31/01)N Page 6 |
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| SDNY_GM_00000724 |
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| EFTA_00114808 |
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| EFTA01263130 |
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| |
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| ## B. Affiliations |
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| 8. a. Have you EVER been a member of or associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other place? |
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| ```markdown |
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| □ Yes ☑ No |
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| ``` |
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| b. If you answered "Yes," list the name of each group below. If you need more space, attach the names of the other group(s) on a separate sheet of paper. |
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| <table border="1"><tr><td>Name of Group</td><td>Name of Group</td></tr><tr><td>1.</td><td>6.</td></tr><tr><td>2.</td><td>7.</td></tr><tr><td>3.</td><td>8.</td></tr><tr><td>4.</td><td>9.</td></tr><tr><td>5.</td><td>10.</td></tr></table> |
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| 9. Have you EVER been a member of or in any way associated (either directly or indirectly) with: |
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| a. The Communist Party? |
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| ☐Yes ☑No |
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| b. Any other totalitarian party? |
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| ☐Yes ☑No |
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| c. A terrorist organization? |
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| ☐Yes ☑No |
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| 10. Have you EVER advocated (either directly or indirectly) the overthrow of any government by force or violence? Yes No |
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| 11. Have you EVER persecuted (either directly or indirectly) any person because of race, religion, national origin, membership in a particular social group, or political opinion? Yes |
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| 12. Between March 23, 1933,and May 8, 1945, did you work for or associate in any way (either directly or indirectly) with: |
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| ## C. Continuous Residence |
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| 14. Have you EVER failed to file a Federal, state, or local tax return because you considered yourself to be a "nonresident"? |
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| Since becoming a Lawful Permanent Resident of the United States: |
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| a. The Nazi government of Germany? |
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| 13. Have you EVER called yourself a "nonresident" on a Federal, state, or local tax return? |
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| b. Any government in any area (1) occupied by, (2) allied with, or (3) established with the help of the Nazi government of Germany? |
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| c. Any German, Nazi. or S.S. military unit, paramilitary unit, self-defense unit, vigilante unit, citizen unit, police unit, government agency or office, extermination camp, concentration camp, prisoner of war camp, prison, labor camp, or transit camp? |
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| |
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| |
| |
| |
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| ```markdown |
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| SDNY_GM_00000725 |
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| ``` |
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| EFTA_00114809 |
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| EFTA01263131 |
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| Part 10 Additional Questions (Continued) |
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| Write your INS "A" - number here: |
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| ## D. Good Moral Character |
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| For the purposes of this application, you must answer "Yes" to the following questions, if applicable, even if your records were scaled or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. |
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| 15. Have you EVER committed a crime or offense for which you were NOT arrested? Yes |
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| 16. Have you LVER been arrested, cited, or detained by any law enforcement officer including INS and military officers) for any reason? |
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| ☐ Yes ☑ Nr |
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| 17. Have you EVER been charged with committing any crime or offense? Yes No |
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| 18. Have you EVER been convicted of a crime or offense? Yes No |
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| 19. Have you EVER been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)? □Yes ☑No |
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| 20. Have you EVER received a suspended sentence, been placed on probation, or been paroled? Yes No |
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| 21. Have you EVER been in jail or prison? Yes No |
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| If you answered "Yes" to any of questions 15 through 21, complete the following table. If you need more space, use a separate sheet of paper to give the same information. |
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| <table border="1"><tr><td>Why were you arrested, cited, detained, or charged?</td><td>Date arrested, cited, detained, or charged(Month/Day/Year)</td><td>Where were you arrested,cited, detained or charged?(City,State,Country)</td><td>Outcome or disposition of the arrest,citation,detention or charge(No charges filed,charges dismissed,jail,probation,etc.)</td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td></tr></table> |
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| Answer questions 22 through 33. If you answer "Yes" to any of these questions, attach (1) your written explanation why your answer was "Yes," and (2) any additional information or documentation that helps explain your answer. |
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| ## 22. Have you EVER: |
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| b. been a prostitute, or procured anyone for prostitution? Yes No |
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| c. sold or smuggled controlled substances, illegal drugs or narcotics? $ \Box $ Yes $ \checkmark $ No |
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| d. been married to more than one person at the same time? Yes No |
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| e. helped anyone enter or try to enter the United States illegally? Yes No |
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| f. gambled illegally or received income from illegal gambling? |
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| [ ] Yes [✓] No |
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| g. failed to support your dependents or to pay alimony? |
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| 23. Have you EVER given false or misleading information to any U.S. government official while applying for any immigration benefit or to prevent deportation, exclusion, or removal? $ \Box $ Yes $ \checkmark $ No |
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| 24. Have you EVER lied to any U.S. government official to gain entry or admission into the United States? Yes No |
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| Form N-40 SDNY_GM_000007268 |
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| EFTA_00114810 |
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| EFTA01263132 |
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| Write your JNS "A"- number here: |
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| Part 10. Additional Questions (Continued) |
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| ## E. Removal, Exclusion, and Deportation Proceedings |
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| 25. Are removal, exclusion, rescission or deportation proceedings pending against you? Yes No |
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| 26. Have you EVER been removed, excluded, or deported from the United States? Yes No |
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| 27. Have you EVER been ordered to be removed, excluded or deported from the United States? $ \Box $ |
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| 25. Have you EVER applied for any kind of relief from removal, exclusion, or deportation? |
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| ## F. Military Service |
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| 29. Have you EVER served in the U.S. Armed Forces? |
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| 30. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces? |
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| 31. Have you EVER applied for any kind of exemption from military service in the U.S. Armed Forces? $ \Box $ Yes $ \checkmark $ No |
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| 32. Have you EVER deserted from the U.S. Armed Forces? |
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| ## G. Selective Service Registration |
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| 33. Are you a male who lived in the United States at any time between your 18th and 26th birthdays in any status except as a lawful nonimmigrant? |
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| ```markdown |
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| $$\Box \text{Yes}$$ |
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| ``` |
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| If you answered "NO", go on to question 34. |
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| If you answered "YES", provide the information below. |
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| If you answered "YES", but you did NOT register with the Selective Service System and are still under 26 years of age, you must register before you apply for naturalization, so that you can complete the information below: |
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| Date Registered (Month/Day/Year) |
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| |
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| Selective Service Number |
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| If you answered "YES", but you did NOT register with the Selective Service and you are now 26 years old or older, attach a statement explaining why you did not register. |
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| ## H. Oath Requirements (See Part 14 for the text of the oath) |
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| Answer questions 34 through 39. If you answer "No" to any of these questions, attach (1) your written explanation why the answer was "No" and (2) any additional information or documentation that helps to explain your answer. |
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| 34. Do you support the Constitution and form of government of the United States? |
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| 35. Do you understand the full Oath of Allegiance to the United States? |
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| 36. Are you willing to take the full Oath of Allegiance to the United States? |
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| 37. If the law requires it, are you willing to bear arms on behalf of the United States? |
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| 38. If the law requires it, are you willing to perform noncombatant services in the U.S. Armed Forces? |
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| 39. If the law requires it, are you willing to perform work of national importance under civilian direction? |
| |
| |
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| Form N-4*SDNY.GM100000727*: 9 |
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| EFTA_00114811 |
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| EFTA01263133 |
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| ```markdown |
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| SDNY_GM_00000728 |
| ``` |
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| EFTA_00114812 |
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| EFTA01263134 |
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| OMB No. 1115-0053 |
| |
| Application to Register Permanent Residence or Adjust Status |
| |
| ```markdown |
| |
| START HERE - Please Type or Print |
| ``` |
| |
| Part 1. Information about you. |
| |
| <table border="1"><tr><td colspan="2">Family Name Maxwell</td><td>Given Name Ghislaine</td><td>Middle Initial N</td></tr><tr><td colspan="4">Address - C/O The Villard House</td></tr><tr><td colspan="4">Street Number and Name</td></tr><tr><td colspan="4">City New York</td></tr><tr><td colspan="2">State New York</td><td colspan="2">Zip Code 10022 10021</td></tr><tr><td colspan="2">Date of Birth(month/day/year)</td><td colspan="2">Country of Birth France</td></tr><tr><td colspan="2">Social Security #</td><td colspan="2">A #(if any)None</td></tr><tr><td colspan="2">Date of Last Arrival(month/day/year)9/19/95</td><td colspan="2">95#70051451304</td></tr><tr><td colspan="2">Current INS StatusH-1B Visa</td><td colspan="2">Expires on(month/day/year)11/4/95</td></tr></table> |
| |
| Part 2. Application Type. (check one) |
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| a. $ \Box $ an immigrant petition giving me an immediately available immigrant visa number has been approved (attach a copy of the approval notice), or a relative, special immigrant juvenile, or special immigrant military visa petition filed with this application will give me an immediately available visa number if approved. |
| |
| b. □ My spouse or parent applied for adjustment of status or was granted lawful permanent residence in an immigrant visa category which allows derivative status for spouses and children. |
| |
| c. $ \Box $ I entered as a K-1 fiance(e) of a U.S. citizen whom I married within 90 days of entry, or I am the K-2 child of such a fiance(e) (attach a copy of the fiance(e) petition approval notice and the marriage certificate). |
| |
| d. $ \Box $ I was granted asylum or derivative asylum status as the spouse or child of a person granted asylum and am eligible for adjustment. |
| |
| e. $ \Box $ I am a native or citizen of Cuba admitted or paroled into the U.S. after January 1, 1959, and thereafter have been physically present in the U.S. for at least 1 year. |
| |
| f. □ I am the husband, wife, or minor unmarried child of a Cuban described in (e) and am residing with that person, and was admitted or paroled into the U.S. after January 1, 1959, and thereafter have been physically present in the U.S. for at least 1 year. |
| |
| g. $ \Box $ I have continuously resided in the U.S. since before January 1, 1972. |
| |
| h. Other-explain DV-96 Registration selected (see attached) |
| |
| I am already a permanent resident and am applying to have the date I was granted permanent residence adjusted to the date I originally arrived in the U.S. as a nonimmigrant or parolee, or as of May 2, 1964, whichever is later, and: *(Check one)* |
| |
| i. $ \Box $ I am a native or citizen of Cuba and meet the description in (e), above. |
| |
| j. □ I am the husband, wife or minor unmarried child of a Cuban, and meet the description in (f), above. |
| |
| Continued on back. |
| |
| <table border="1"><tr><td>Returned</td><td rowspan="6">Receipt |
| RECEIVED INFORMATION |
| OCT 12 1995 |
| Immigration and Naturalization Service New York, N.Y. |
| RECEIVED |
| S2 FLOOR CASHIER |
| OCT 12 1995 |
| Immigration and Naturalization Service New York, N.Y.</td></tr><tr><td>Resubmitted</td></tr><tr><td>Reloc Sent</td></tr><tr><td>Reloc Rec'd</td></tr><tr><td>Applicant Interviewed</td></tr><tr><td colspan="2">Section of Law |
| ☐ Sec. 209(b), INA |
| ☐ Sec. 13, Act of 9/11/57 |
| ☐ Sec. 245, INA |
| ☐ Sec. 249, INA |
| ☐ Sec. 1 Act of 11/2/66 |
| ☐ Sec. 2 Act of 11/2/66 |
| ☐ Other</td></tr><tr><td colspan="2">Country Chargeable |
| France</td></tr><tr><td colspan="2">Eligibility Under Sec. 245 |
| ☐ Approved Visa Petition |
| ☐ Dependent of Principal Alien |
| ☐ Special Immigrant |
| ☐ Other</td></tr><tr><td colspan="2">Preference</td></tr><tr><td colspan="2">Action Block |
| APPROVED |
| INE DISTRICT DIRECTOR |
| FEB 0 9 1996 |
| Programmed by |
| NYC | 0812</td></tr><tr><td colspan="2">To Be Completed by |
| Attorney or Representative, if any |
| ☐ Fill in box if G-28 is attached to represent the applicant</td></tr><tr><td colspan="2">VOLAG#</td></tr><tr><td colspan="2">ATTY State License # |
| SDNY_GM_00000729</td></tr></table> |
| |
| Form I-485 (09-09-92)N |
| |
| EFTA_00114813 |
|
|
| EFTA01263135 |
|
|
| Part 3. Processing Information. |
|
|
| A. City/Town/Village of birth |
| Maison Laffitte |
| Your mother's first name |
| Elizabeth |
| Your father's first name |
| Robert |
|
|
| Give your name exactly how it appears on your Arrival /Departure Record (Form I-94) |
| Maxwell, Ghislaine |
|
|
| Place of last entry into the U.S. (City/State) |
| New York, New York |
|
|
| Where you inspected by a U.S. Immigration Officer? ☐ Yes □ No |
|
|
| Nonimmigrant Visa Number |
| 1/15/93 |
|
|
| Date Visa was issued |
| (month/day/year) |
|
|
| Sex: ☐ Male ☐ Female |
|
|
| Marital Status: ☐ Married ☐ Single ☐ Divorced ☐ Widowed |
|
|
| Have you ever before applied for permanent resident status in the U.S? ☐ No ☐ Yes (give date and place of filing and final disposition): |
|
|
| B. List your present husband/wife, all of your sons and daughters (if you have none, write "none"). If additional space is needed, use separate paper. |
|
|
| Family Name NONE |
| Given Name |
| Middle Initial |
| Date of Birth (month/day/year) |
|
|
| Country of birth |
| Relationship |
| A # |
| Applying with you? ☐ Yes ☐ No |
|
|
| Family Name |
| Given Name |
| Middle Initial |
| Date of Birth (month/day/year) |
|
|
| Country of birth |
| Relationship |
| A # |
| Applying with you? ☐ Yes ☐ No |
|
|
| Family Name |
| Given Name |
| Middle Initial |
| Date of Birth (month/day/year) |
|
|
| Country of birth |
| Relationship |
| A # |
| Applying with you? ☐ Yes ☐ No |
|
|
| Family Name |
| Given Name |
| Middle Initial |
| Date of Birth (month/day/year) |
|
|
| Country of birth |
| Relationship |
| A # |
| Applying with you? ☐ Yes ☐ No |
|
|
| C. List your present and past membership in or affiliation with every political organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other place since your 16th birthday. Include any foreign military service in this part. If none, write "none". Include the name of organization, location, dates of membership from and to, and the nature of the organization. If additional space is needed, use separate paper. |
|
|
| NONE |
|
|
| Form I-485 (Rev. 09-09-92) N |
|
|
| Continued On Next Page |
|
|
| ```markdown |
| |
| SDNY_GM_00000730 |
| ``` |
|
|
| ```markdown |
| |
| ``` |
|
|
| EFTA_00114814 |
| |
| EFTA01263136 |
| |
| Please answer the following questions. (If your answer is "Yes" on any one of these questions, explain on a separate piece of paper. Answering "Yes" does not necessarily mean that you are not entitled to register for permanent residence or adjust status). |
| |
| 1. Have you ever, in or outside the U.S.: |
| a. knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested? |
| b. been arrested, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violation? |
| c. been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action? |
| d. exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S. |
| |
| □ Yes No |
| |
| 2. Have you received public assistance in the U.S. from any source, including the U.S. government or any state, county, city, or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future? |
| |
| □ Yes No |
| |
| 3. Have you ever: |
| a. within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future? |
| b. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling? |
| c. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally? |
| d. illicitly trafficked in any controlled substance, or knowingly assisted, abetted or cofused in the illicit trafficking of any controlled substance? |
| |
| □ Yes No |
| |
| 4. Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or funds for, or have you through any means ever assured or provided any type of material support to, any person or organization that has ever engaged or conspired to engage, in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity? |
| |
| □ Yes No |
| |
| 5. Do you intend to engage in the U.S. in: |
| a. espionage? |
| b. any activity a purpose of which is opposition to, or the control or overthrow of, the Government of the United States, by force, violence or other unlawful means? |
| c. any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information? |
| |
| □ Yes No |
| |
| 6. Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party? |
| |
| □ Yes No |
| |
| 7. Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever inole, assist or otherwise participate in the persecution of any person because of race, religion, national origin or political opinion? |
| |
| □ Yes No |
| |
| 8. Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin, or political opinion? |
| |
| □ Yes No |
| |
| 9. Have you ever been deported from the U.S. or removed from the U.S. at government expense, excluded within the past year, or are you now in exclusion or deportation proceedings? |
| |
| □ Yes No |
| |
| 10. Are you under a final order of civil penalty for violating section 274C of the Immigration Act for use of fraudulent documents, or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S., or any other immigration tribunal? |
| |
| □ Yes No |
| |
| 11. Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces? |
| |
| □ Yes No |
| |
| 12. Have you ever been a J nonimmigrant visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver? |
| |
| □ Yes No |
| |
| 13. Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child? |
| |
| □ Yes No |
| |
| 14. Do you plan to practice polygamy in the U.S.? |
| |
| Form I-485 (Rev. 09-09-92)N |
| |
| Continued on back |
| |
| ```markdown |
| |
| SDNY_GM_00000731 |
| ``` |
| |
| EFTA_00114815 |
|
|
| EFTA01263137 |
|
|
| Part 4. Signature. (Read the information on penalties in the instructions before completing this section. You must file this application while in the United States.) |
|
|
| I certify under penalty of perjury under the laws of the United States of America that this application, and the evidence submitted with it, is all true and correct. I authorize the release of any information from my records which the Immigration and Naturalization Service needs to determine eligibility for the benefit. I am seeking. |
|
|
| Signature |
|
|
| Print Your Name |
|
|
| Ghislaine Maxwell |
|
|
| Date |
|
|
| 10/6/95 |
|
|
| Daytime Phone Number |
|
|
| Please Note: If you do not completely fill out this form, or fail to submit required documents listed found eligible for the requested document and this application may be denied. |
|
|
| Part 5. Signature of person preparing form if other than above. (Sign Below) |
|
|
| <table border="1"><tr><td>Signature</td><td>Print Your Name</td><td>Date</td><td>Day time Phone Number</td></tr><tr><td>Firm Nameand Address</td><td></td><td></td><td></td></tr></table> |
|
|
| Form 1-485 (Rev. 09-09-92) N |
|
|
| ```markdown |
| |
| SDNY_GM_00000732 |
| ``` |
|
|
| EFTA_00114816 |
| |
| EFTA01263138 |
| |
| ```markdown |
| |
| 1 |
| ``` |
| |
| U.S. Department of Justice |
| |
| Immigration and Naturalization Service |
| |
| OMB #1115-0005 |
| |
| * Application for Travel Document |
| |
| Part 1. Information about you. |
| |
| <table border="1"><tr><td colspan="2">Family Name Maxwell</td><td colspan="2">Given Name Ghislaine</td><td>Middle Initial N</td></tr><tr><td colspan="5">Address C/O</td></tr><tr><td colspan="3">Street Number and Name</td><td colspan="2">Apt. # A</td></tr><tr><td colspan="3">City New York</td><td colspan="2">State or Province NY</td></tr><tr><td colspan="3">Country USA</td><td colspan="2">ZIP/Postal Code 10021</td></tr><tr><td colspan="2">Date of Birth(Month/Day/Year)</td><td colspan="3">Country of Birth France</td></tr><tr><td colspan="2">Social Security #</td><td>A#</td><td colspan="2"></td></tr></table> |
| |
| Part 2. Application Type (check one). |
| |
| a. ☐ I am a permanent resident or conditional resident of the United States and I am applying for a Reentry Permit. |
| |
| b. ☐ I now hold U.S. refugee or asylee status and I am applying for a Refugee Travel Document. |
| |
| c. ☐ I am a permanent resident as a direct result of refugee or asylee status, and am applying for a Refugee Travel Document. |
| |
| d. ☑ I am applying for an Advance Parole to allow me to return to the U.S. after temporary foreign travel. |
| |
| e. ☐ I am outside the U.S. and am applying for an Advance Parole. |
| |
| f. ☐ I am applying for an Advance Parole for another person who is outside the U.S. Give the following information about that person: N/A |
| |
| | Family Name | Given Name | Middle Initial | |
| | :--- | :--- | :--- | |
| | Date of Birth (Month/Day/Year) | Country of Birth | | |
| |
| **Foreign Address - C/O** |
| |
| | Street Number and Name | Apt. # | |
| | :--- | :--- | |
| | City | State or Province | |
| | Country | ZIP/Postal Code | |
| |
| Part 3. Processing Information. |
| |
| <table border="1"><tr><td colspan="2">Date of Intended departure(Month/Day/Year)10/31/95</td><td>Expected length of trip1 week to 10 days</td></tr><tr><td colspan="3">Are you, or any person included in this application, now in exclusion or deportation proceedings?☐No ☐Yes, at(give office name)</td></tr><tr><td colspan="3">If applying for an Advance Parole Document,skip to Part7.</td></tr><tr><td colspan="3">Have you ever before been issued a Reentry Permit or Refugee Travel Document?☐No ☐Yes(give the following for the last document issued to you)</td></tr><tr><td>N/A</td><td>Date Issued</td><td>Disposition(attached, lost, etc.)</td></tr></table> |
| |
| Form I-131 (Rev. 12/10/91) N |
| |
| # FOR INS USE ONLY |
| |
| | Returned | Receipt | |
| | :--- | :--- | |
| | ___ | ___ | |
| | Resubmitted | ___ | |
| | ___ | ___ | |
| | Reloc Sent | ___ | |
| | ___ | ___ | |
| | Reloc Rec’d | ___ | |
| | ___ | ___ | |
| | □ Applicant Interviewed on | | |
| |
| **Document Issued:** |
| - □ Reentry Permit |
| - □ Refugee Travel Document |
| - □ Single Advance Parole |
| - □ Multiple Advance Parole |
| Validity to ___ |
|
|
| **If Reentry Permit or Refugee Travel Document** |
| - □ Mail to Address in Part 2 |
| - □ Mail to American Consulate |
| - □ Mail to INS overseas office |
| AT |
|
|
| **Remarks:** |
| - □ Document Hand Delivered |
| On By |
|
|
| **Action Block** |
|
|
| *Denied* |
| Assured as expected |
| 10/17/15 |
| MC 1018195 |
|
|
| **To Be Completed by Attorney or Representative, if any** |
| - □ Fill in box if G-28 is attached to represent the applicant |
|
|
| **VOLAG#** |
|
|
| **ATTY State ID:** SONYE_GM_00000733 |
|
|
| EFTA_00114817 |
| |
| EFTA01263139 |
| |
| # Part 3. Processing Information. (continued) |
| |
| Where do you want this travel document sent? (check one) N/A |
| |
| a. □ Address in Part 2, above |
| b. American Consulate at (give City and Country, below) |
| c. INS overseas office at (give City and Country, below) |
| City Country |
| |
| If you checked b. or c., above, give your overseas address: |
| |
| ## Part 4. Information about the Proposed Travel. N/A |
| |
| Purpose of trip. If you need more room, continue on a separate sheet of paper. |
| |
| List the countries you intend to visit. |
| |
| ## Part 5. Complete only if applying for a Reentry Permit. N/A |
| |
| Since becoming a Permanent Resident (or during the past five years, whichever is less) how much total time have you spent outside the United States? |
| |
| □ less than 6 months □ 2 to 3 years |
| □ 6 months to 1 year □ 3 to 4 years |
| □ 1 to 2 years □ more than 4 years |
| |
| Since you became a Permanent Resident, have you ever filed a federal income tax return as a nonresident, or failed to file a federal return because you considered yourself to be a nonresident? (if yes, give details on a separate sheet of paper) |
| |
| □ Yes □ No |
| |
| ## Part 6. Complete only if applying for a Refugee Travel Document. N/A |
| |
| Country from which you are a refugee or asylie: |
| If you answer yes to any of the following questions, explain on a separate sheet of paper. |
| |
| Do you plan to travel to the above-named country? |
| |
| □ Yes □ No |
| |
| Since you were accorded Refugee/Ayyle status, have you ever: returned to the above-named country; applied for prior obtained a national passport, passport renewal, or entry permit into the country; or applied for prior received any benefit from such country (for example, health insurance benefits)? |
| |
| □ Yes □ No |
| |
| Since being accorded Refugee/Ayyle status, have you, by any legal procedure or voluntary act, re-acquired the nationality of the above-named country, acquired a new nationality, or been granted refugee or ayyle status in any other country? |
| |
| □ Yes □ No |
| |
| ## Part 7. Complete only if applying for an Advance Parole. |
| |
| On a separate sheet of paper, please explain how you qualify for an Advance Parole and what circumstances warrant issuance of Advance Parole. Include copies of any documents you will consider. (See instructions.) |
| |
| □ 1 trip More than 1 trip |
| |
| For how may trips do you intend to use this document? |
| If outside the U.S., at right give the U.S. Consulate or IRS office you wish notified if this application is approved. |
| |
| ## Part 8. Signature. |
| |
| Read the information on penalties in the instructions before completing this section. You must file this application when in the United States if filing for a reentry permit or refugee travel document. |
| |
| I certify under penalty of perury under the laws of the United States of America that this petition, and the evidence submitted with it, is a true and correct. |
| |
| I authorize the release of any information from my records which the Immigration and Naturalization Service needs to determine eligibility for the benefit I am seeking. |
| |
| Signature Date 10/6/95 Detime Telephone # |
| |
| Please Note: If you do not completely fill out this form, or fail to submit required documents listed in the instructions, you may not be found eligible for the requested document and this application will have to be denied. |
| |
| ## Part 9. Signature of person preparing form if other than above. (sign below) |
| |
| I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge. |
| |
| Signature Print Your Name Date |
| |
| Firth Name Daytime Telephone # |
| and Address ( ) |
| |
| EFTA01263140 |
| |
| Part 3. Processing Information. (continued) |
| |
| # Part 4. Information about the Proposed Travel. |
| |
| N/A |
| |
| Purpose of trip. If you need more room, continue on a separate sheet of paper. |
| |
| List the countries you intend to visit. |
| |
| ## Part 5. Complete only if applying for a Reentry Permit. |
| |
| N/A |
| |
| Since becoming a Permanent Resident (or during the past five years, whichever is less) how much total time have you spent outside the United States? |
| |
| □ less than 6 months |
| □ 6 months to 1 year |
| □ 1 to 2 years |
| □ more than 4 years |
| |
| Since you became a Permanent Resident, have you ever filed a federal income tax return as a nonresident, or tailed to file a federal return because you considered yourself to be a nonresident? If yes, give details on a separate sheet of paper. |
| |
| □ Yes |
| □ No |
| |
| ## Part 6. Complete only if applying for a Refugee Travel Document. |
| |
| N/A |
| |
| Country from which you are a refugee or asylee: |
| |
| If you answer yes to any of the following questions, explain on a separate sheet of paper. |
| |
| Do you plan to travel to the above-named country? |
| |
| □ Yes |
| □ No |
| |
| Since you were accorded Refugee/Aysee status, have you ever: returned to the above-named country, applied for an avior obtained a national passport, passport renewal, or entry permit into this country, or applied for an avior received any benefit from such country (for example, health insurance benefits)? |
| |
| □ Yes |
| □ No |
| |
| Since being accorded Refugee/Aysee status, have you, by any legal procedure or voluntary act, re-acquired the nationality of the above-named country, acquired a new nationality, or been granted refugee or asylee status in any other country? |
| |
| □ Yes |
| □ No |
| |
| ## Part 7. Complete only if applying for an Advance Parole. |
| |
| On a separate sheet of paper, please explain how you qualify for an Advance Parole and what circumstances warrant issuance of Advance Parole. Include copies of any documents you wish considered. (See instructions.) |
| |
| For how may trips do you intend to use this document? |
| |
| □ 1 trip |
| □ More than 1 trip |
| |
| If outside the U.S., at right give the U.S. Consultate or INS office you wish notified if this application is approved. |
| |
| Signature |
| |
| Date |
| |
| 10/6/95 |
| |
| Please Note: If you do not completely fill out this form, or fail to submit required documents listed in the instructions, you may not be found eligible for the requested document and this application will have to be denied. |
| |
| ## Part 8. Signature of person preparing form if other than above. (sign below) |
| |
| I declare that I prepared this application at the request of the above person and is based on all information of which I have knowledge. |
| |
| Signature |
| |
| Print Your Name |
| |
| Date |
| |
| Firm Name |
| |
| Daytime Telephone # |
| |
| and Address |
| |
| ( ) |
| |
| ★ U.S. GPO:1994-301-164/92741 |
| |
| SDNY.GM.0000735 |
| |
| EFTA_00114819 |
|
|
| EFTA01263141 |
|
|
|
|
|
|
| GHISLAINE N.M MAXWELL |
|
|
| ```markdown |
| |
| SDNY_GM_00000736 |
| ``` |
|
|
| EFTA_00114820 |
| |
| EFTA01263142 |
| |
| U.S. Department of Justice |
| |
| Immigration and Naturalization Service |
| |
| OMB #1115-0005 |
| |
| Application for Travel Document |
| |
| ## ```markdown |
| |
| START HERE - Please Type or Print |
| ``` |
| |
| Part 1. Information about you. |
| |
| <table border="1"><tr><td>Family Name Maxwell</td><td colspan="2">Given Name Ghislaine</td><td>Middle Initial N</td></tr><tr><td colspan="4">Address C/O</td></tr><tr><td colspan="3">Street Number and Name</td><td>Apt. # 8A</td></tr><tr><td colspan="2">City New York</td><td colspan="2">State or Province NY</td></tr><tr><td colspan="2">Country USA</td><td colspan="2">ZIP/Postal Code 10021</td></tr><tr><td colspan="2">Date of Birth(Month/Day/Year)</td><td colspan="2">Country of Birth France</td></tr><tr><td colspan="2">Social Security #</td><td colspan="2">A#</td></tr></table> |
| |
| Part 2. Application Type (check one). |
| |
| a. □ I am a permanent resident or conditional resident of the United States and I am applying for a Reentry Permit. |
| |
| b. □ I now hold U.S. refugee or asylee status and I am applying for a Refugee Travel Document. |
| |
| c. □ I am a permanent resident as a direct result of refugee or asylee status, and am applying for a Refugee Travel Document. |
| |
| d. ☑ I am applying for an Advance Parole to allow me to return to the U.S. after temporary foreign travel. |
| |
| e. □ I am outside the U.S. and am applying for an Advance Parole. |
| |
| f. □ I am applying for an Advance Parole for another person who is outside the U.S. Give the following information about that person: |
| |
| | Family Name | Given Name | Middle Initial | |
| | :--- | :--- | :--- | |
| | Date of Birth (Month/Day/Year) | Country of Birth | | |
| |
| **Foreign Address - C/O** |
| |
| | Street Number and Name | Apt. # | |
| | :--- | :--- | |
| | City | State or Province | |
| | Country | ZIP/Postal Code | |
| |
| Part 3. Processing Information. |
| |
| <table border="1"><tr><td colspan="2">Date of Intended departure(Month/Day/Year)10/17/95</td><td>Expected length of trip1 week to 10 days</td></tr><tr><td colspan="3">Are you, or any person included in this application, now in exclusion or deportation proceedings?☐No ☐Yes, at(give office name)</td></tr><tr><td colspan="3">If applying for an Advance Parole Document,skip to Part7.</td></tr><tr><td colspan="3">Have you ever before been issued a Reentry Permit or Refugee Travel Document?☐No ☐Yes(give the following for the last document issued to you)N/A Date Issued Disposition(attached, lost, etc.)</td></tr></table> |
| |
| Form I-131 (Rev. 12/10/91) N |
| |
| Continued on back. |
| |
| $$\begin{array}{l} |
| |
| 08.11 \\ |
| |
| 2 \\ |
| |
| 370.00 |
| |
| \end{array}$$ |
| |
| # FOR INS USE ONLY |
| |
| | Returned | Receipt | |
| | :--- | :--- | |
| | ___ | ___ | |
| | Resubmitted | ___ | |
| | ___ | ___ | |
| | Reloc Sent | RECEIVED 3rd FLOOR CASHIER OCT 17 1995 Immigration and Naturalization Service New York, N.Y. | |
| | ___ | ___ | |
| | Reloc Rec'd | ___ | |
| | ___ | ___ | |
| | □ Applicant Interviewed on | | |
|
|
| **Document Issued** |
| - □ Reentry Permit |
| - □ Refugee Travel Document |
| - □ Single Advance Parole |
| - □ Multiple Advance Parole |
| Validity to **OCT 17, 1996** |
|
|
| **If Reentry Permit or Refugee Travel Document** |
| - □ Mail to Address in Part 2 |
| - □ Mail to American Consulate |
| - □ Mail to INS overseas office |
| AT |
|
|
| **Remarks:** |
| - □ Document Hand Delivered |
| On By |
|
|
| **Action Block** |
|
|
| **To Be Completed by Attorney or Representative, if any** |
| - □ Fill in box if G-28 is attached to represent the applicant |
|
|
| **VOLAG#** |
|
|
| **ATTY State ID:** M_00000737 |
| |
| APPROVED |
| |
| OCT 17 1995 |
| |
| NYC | 5329 |
| |
| EFTA_00114821 |
|
|
| EFTA01263143 |
|
|
| # Part 3. Processing Information. (continued) |
|
|
| Where do you want this travel document sent? (check one) N/A |
|
|
| a. □ Address in Part 2, above |
| b. □ American Consulate at (give City and Country, below) |
| c. □ INS overseas office at (give City and Country, below) |
| City Country |
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| If you checked b. or c., above, give your overseas address: |
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| ## Part 4. Information about the Proposed Travel. N/A |
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| | Purpose of trip. If you need more room, continue on a separate sheet of paper. | List the countries you intend to visit. | |
| | :--- | :--- | |
| | | | |
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| ## Part 5. Complete only if applying for a Reentry Permit. N/A |
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| - [ ] less than 6 months [ ] 2 to 3 years |
| - [ ] 6 months to 1 year [ ] 3 to 4 years |
| - [ ] 1 to 2 years [ ] more than 4 years |
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| Since becoming a Permanent Resident (or during the past five years, whichever is less) how much total time have you spent outside the United States? |
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| Since you became a Permanent Resident, have you ever filed a federal income tax return as a nonresident, or failed to file a federal return because you considered yourself to be a nonresident? (if yes, give details on a separate sheet of paper). |
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| [ ] Yes [ ] No |
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| Part 6. Complete only if applying for a Refugee Travel Document. N/A |
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| <table border="1"><tr><td colspan="3">Country from which you are a refugee or asylee:</td></tr><tr><td colspan="3">If you answer yes to any of the following questions, explain on a separate sheet of paper.</td></tr><tr><td>Do you plan to travel to the above-named country?</td><td>Yes</td><td>No</td></tr><tr><td>Since you were accorded Refugee/Asylee status, have you ever: returned to the above-named country; applied for an/or obtained a national passport, passport renewal, or entry permit into this country; or applied for an/or received any benefit from such country(for example, health insurance benefits)?</td><td>Yes</td><td>No</td></tr><tr><td>Since being accorded Refugee/Asylee status, have you, by any legal procedure or voluntary act, re-acquired the nationality of the above-named country, acquired a new nationality, or been granted refugee or asylee status in any other country?</td><td>Yes</td><td>No</td></tr></table> |
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| Part 7. Complete only if applying for an Advance Parole. |
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| On a separate sheet of paper, please explain how you qualify for an Advance Parole and what circumstances warrant issuance of Advance Parole. Include copies of any documents you wish considered. (See instructions.) |
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| For how may trips do you intend to use this document? |
| ☐ 1 trip |
| More than 1 trip |
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| If outside the U.S., at right give the U.S. Consulate or INS office you wish notified if this application is approved. |
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| For how may trips do you intend to use this document? |
| ☐ 1 trip ☑ More than 1 trip |
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| If outside the U.S., at right give the U.S. Consulate or INS office you wish notified if this application is approved. |
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| **Part 8. Signature.** |
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| Read the information on penalties in the instructions before completing this section. You must file this application while in the United States if filing for a reentry permit or refugee travel document. |
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| I certify under penalty of perjury under the laws of the United States of America that this petition, and the evidence submitted with it, is all true and correct. I authorize the release of any information from my records which the Immigration and Naturalization Service needs to determine eligibility for the benefit. I am seeking. |
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| **Signature** |
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| Date 10/16/95 |
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| Daytime Telephone # (212) 750-9895 |
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| **Please Note:** If you do not completely fill out this form, or fail to submit required documents listed in the instructions, you may not be found eligible for the requested document and this application will have to be denied. |
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| Part 9. Signature of person preparing form if other than above. (sign below) |
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| <table border="1"><tr><td>Signature</td><td>Print Your Name</td><td>Date</td></tr><tr><td>Firm Nameand Address</td><td></td><td>Daytime Telephone#( )</td></tr></table> |
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| EFTA_00114822 |
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| EFTA01263144 |
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