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or print in black ink Part 1. Information About You U.S. Physical Address To Be Completed by an Attorney or Accredited Representative, if any. K Select this box if Form O-28 is attached to represent the applicant. Attorney State License Number I. Alien Registration Number (A-Number) 6.a. In Ca
io laws. nature 3.b. Date of Signature (mm/dd/yyyy) ► 1.11Lt /iota) Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the fo
amp Action Block Valid From K Authorization/Extension Valid Through Alien Registration Number A- , Remarks To be completed by an attorney or K Select this box if Form G-28 Attorney or Accredited Representative Board of Immigration Appeals (BIA)- accredited representative (if any). is attached.
e, and correct. Applicant's Contact Information Applicant's Signature 3. Applicant's Daytime Telephone Number 7.a. A licant's Si nature S 4. Applicant's Mobile Telephone Number (if any) 7.b. Date of Signature (mm/dd/yyyy) oi./I412620 5. A licant's Email Address (if any) NOTE TO ALL APPLICANTS: If you do out this appli
U.S. physical address in Item Numbers 6.a. - 6.1. 1 1 La. In Care Of Name To Be Completed by an Attorney or Aerredited Representative, if any. K Select this box if Form G-28 is attached to represent the applicant. Attorney State License Number Lb. Street Nut and Name 6.c. Apt. 0 Ste. 0 FIr.
3.a. Applicant's Signature S 3.b. Date of Signature (mm/dd/yyyy) ► Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the fo
Entities connected to both K Select and Applicant's Mobile Telephone Number

Jeffrey Epstein
PERSON
Homeland Security
ORGANIZATIONAlbany
LOCATIONU.S. Citizenship and Immigration Services
ORGANIZATION
Department of Homeland Security
ORGANIZATIONthe Social Security Administration
ORGANIZATIONNew York Field Office
LOCATION
Michael C.Green
PERSONthe NYS Division of Criminal Justice Services
ORGANIZATIONHomeland Security Investigations
ORGANIZATIONU.S. Immigration and Customs Enforcement
ORGANIZATIONFederal, State
ORGANIZATIONPreparer
ORGANIZATIONNew York State Division of Criminal Justice Services
ORGANIZATIONU.S. Social Security
ORGANIZATIONNational Crime Information Center
ORGANIZATIONParole and Law Enforcement Programs Unit
ORGANIZATIONRequesting Law Enforcement Agency
ORGANIZATIONMonitoring Group
ORGANIZATIONMonitoring Case
ORGANIZATION