<p> DECLARATION </p><p>I, [First Name Last Name], being an adult of sound mind and body, hereby declare under penalty of perjury pursuant to 28 U.S.C. § 1746 that the following is true and accurate to the best of my knowledge and belief: </p><p>1. I am [First Name Last Name]. The following statements are based on my personal </p><p> knowledge.</p><p>2. My name is [First Name Last Name] and I currently reside in [City, State]. </p><p>3. I am a citizen of [Country] and I am the beneficiary of an approved I-140 petition in the </p><p>EB-2 category with a priority date of [ex: August 10, 2010].</p><p>4. When I learned my priority date would allow me to file an Adjustment of Status </p><p> application on October 1, 2015, my attorney and I [or just “I” if no attorney] began </p><p> preparing my application [as well as my family members]. </p><p>5. In reliance on the October 2015 Visa Bulletin, published on September 9, 2015, I spent </p><p> money on the following:</p><p> a. Medical examination/vaccinations: $[amount]</p><p> b. Attorney’s fees: $[amount]</p><p> c. Document retrieval: $[amount]</p><p> d. Translations: $[amount]</p><p> e. Postage and Delivery: $[amount]</p><p> f. [Other costs, please list] $[amount] 6. I also suffered hardship as a result of the revocation of the October 2015 Visa Bulletin </p><p> because [Add other ways you sacrificed, including time off work, cancelled plans other </p><p> financial commitments, etc.].</p><p>7. I am very interested in filing my Adjustment of Status application because [provide </p><p> narrative explaining what filing the application would mean to you].</p><p>I declare under penalty of perjury that the foregoing is true and correct.</p><p>Executed this 29th day of September, 2015, by: </p><p>______Name of Declarant (Please Print)</p><p>______Declarant’s Signature Date</p>