Fillable 20041030d Form I-864, Affidavit of Support Under Section 213A of the INA

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20041030d Form I-864, Affidavit of Support Under Section 213A of the INA

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Form I-864 03/06/18 Page 1 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services
To be completed by an
attorney or accredited
representative (if any).
►
Part 1. Basis For Filing Affidavit of Support
am the sponsor submitting this affidavit of support because
(Select only one box):
I am the petitioner. I filed or am filing for the
immigration of my relative.
I filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my
1.c.
1.d.
I have an ownership interest of at least 5 percent in
I am the only joint sponsor.
1.e.
1.f.
I am the
The original petitioner is deceased. I am the
substitute sponsor. I am the intending immigrant's
first second of two joint sponsors.
which filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my
1.b.
I,
1.a.
Mailing Address
2.d. City or Town
2.e.
State
2.f.
ZIP Code
Country2.i.
2.h.
Postal Code
Street Number and Name2.b.
NOTE: If you are filing this form as a sponsor, you must
include proof of your U.S. citizenship, U.S. national status,
or lawful permanent resident status.
2.c.
Affidavit of Support Submitter Adjusted Household Size
Petitioner
1st Joint Sponsor
2nd Joint Sponsor
Remarks
Date (mm/dd/yyyy):
Reviewed By:
Office:
Substitute Sponsor
5% Owner
Section 213A Review
MEETS
requirements
DOES NOT MEET
requirements
START HERE - Type or print in black ink.
Number of Support Affidavits in File
1
2
,
Province2.g.
Apt. Ste. Flr.
In Care Of Name2.a.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Select this box if
Form G-28 or
G-28I is attached.
1.b. Given Name
(First Name)
1.c.
Middle Name
Part 2. Information About the Principal
Immigrant
1.a. Family Name
(Last Name)
Alien Registration Number (A-Number) (if any)6.
►
A-
USCIS Online Account Number (if any)7.
►
3. Country of Citizenship or Nationality
Other Information
Date of Birth (mm/dd/yyyy)4.
Daytime Telephone Number8.
USCIS
Form I-864
OMB No. 1615-0075
Expires 03/31/2020
For
USCIS
Use
Only
(USPS ZIP Code Lookup)
5. Gender Male Female
Form I-864 03/06/18 Page 2 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Part 2. Information About the Principal
Immigrant (continued)
Relationship to Sponsor9.
1. I am sponsoring the principal immigrant named in Part 2.
2.
I am sponsoring the following family members
immigrating at the same time or within six months of
the principal immigrant named in Part 2. (Do not
include any relative listed on a separate visa petition.)
No (Applicable only if you are sponsoring
family members in Part 3. as the second
joint sponsor or if you are sponsoring
family members who are immigrating
more than six months after the principal
immigrant)
Yes
Part 3. Information About the Immigrants You
Are Sponsoring
3.
I am sponsoring the following family members who
are immigrating more than six months after the principal
immigrant.
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.
Middle Name
5. Relationship to Principal Immigrant
Date of Birth (mm/dd/yyyy)6.
Alien Registration Number (A-Number) (if any)7.
Family Member 1
►
A-
USCIS Online Account Number (if any)8.
►
Middle Name
9.c.
Given Name
(First Name)
9.b.
Family Name
(Last Name)
9.a.
Family Member 2
Relationship to Principal Immigrant10.
11. Date of Birth (mm/dd/yyyy)
12. Alien Registration Number (A-Number) (if any)
►
A-
USCIS Online Account Number (if any)13.
►
Alien Registration Number (A-Number) (if any)17.
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c.
Middle Name
15. Relationship to Principal Immigrant
Date of Birth (mm/dd/yyyy)16.
Family Member 3
►
A-
USCIS Online Account Number (if any)18.
►
Middle Name
19.c.
Given Name
(First Name)
19.b.
Family Name
(Last Name)
19.a.
Family Member 4
21. Date of Birth (mm/dd/yyyy)
Relationship to Principal Immigrant20.
22. Alien Registration Number (A-Number) (if any)
►
A-
USCIS Online Account Number (if any)23.
►
Given Name
(First Name)
24.b.
Family Name
(Last Name)
24.a.
Middle Name
24.c.
Family Member 5
Relationship to Principal Immigrant25.
26. Date of Birth (mm/dd/yyyy)
Form I-864 03/06/18 Page 3 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Part 3. Information About the Immigrants You
Are Sponsoring (continued)
27. Alien Registration Number (A-Number) (if any)
►
A-
USCIS Online Account Number (if any)28.
►
29.
Enter the total number of immigrants you are sponsoring
on this affidavit which includes the principal immigrant
listed in Part 2., any immigrants listed in Part 3., Item
Numbers 1. - 28. and (if applicable), any immigrants
listed for these questions in Part 12. Additional
Information. Do not count the principal immigrant if you
are only sponsoring family members entering more than 6
months after the principal immigrant.
►
Middle Name
1.c.
Given Name
(First Name)
1.b.
Family Name
(Last Name)
1.a.
Sponsor's Full Name
Part 4. Information About You (Sponsor)
Sponsor's Mailing Address
2.d. City or Town
2.e.
State
2.f.
ZIP Code
Country2.i.
2.h.
Postal Code
Street Number and Name2.b.
2.c.
Province2.g.
Apt. Ste. Flr.
In Care Of Name2.a.
NoYes
Is your current mailing address the same as your physical
address?
3.
If you answered "No" to Item Number 3., provide your
physical address in Item Numbers 4.a. - 4.h.
Sponsor's Physical Address
City or Town4.c.
4.h. Country
ZIP Code
4.e.
State
4.d.
4.g.
Postal Code
Street Number and Name4.a.
4.b.
4.f. Province
Apt. Ste. Flr.
Other Information
Date of Birth (mm/dd/yyyy)6.
Country of Domicile5.
8. State or Province of Birth
City or Town of Birth7.
Country of Birth 9.
10. U.S. Social Security Number (Required)
►
Citizenship or Residency
I am a U.S. citizen.
11.b.
I am a U.S. national.
11.a.
11.c.
I am a lawful permanent resident.
Sponsor's A-Number (if any)
►
A-
Sponsor's USCIS Online Account Number (if any)13.
►
12.
Military Service (To be completed by petitioner sponsors only.)
I am currently on active duty in the U.S. Armed Forces,
other than for active duty training.
14.
NoYes
Form I-864 03/06/18 Page 4 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Sponsor's Bank Account Information
Account Type
15.a.
Checking
Savings
15.b. Account Holder's Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
15.c. Name(s) of Joint Account Holders, if any
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
15.d. Institution Name
15.e.
Routing Number15.f.
Account Number
Part 4. Information About You (Sponsor)
(continued)
Part 5. Sponsor's Household Size
NOTE: Do not count any member of your household more
than once.
Individuals you are sponsoring in this affidavit:
1.
2.
3.
4.
Provide the number you entered in Part 3., Item Number
29.
If you have dependent children, enter the total number of
dependent children here.
If you are currently married, enter "1" for your spouse.
Yourself.
Individuals NOT sponsored in this affidavit:
5. If you have any other dependents, enter the total number
of other dependents here.
►
►
►
►
►
6.
If you have sponsored any other persons on Form I-864 or
Form I-864EZ who are now lawful permanent residents
and for whom your support obligation has not ended,
enter the number here.
►
Part 6. Previously Submitted Affidavits of
Support
Have you submitted Form I-864 or Form I-864EZ for any
individuals other than those named on this form?
2. If you answered “Yes” to Item Number 1., enter the total
number of individuals for whom you previously submitted
Form I-864 or Form I-864EZ.
1.
NoYes
►
Provide the following information about each individual
for whom you previously submitted Form I-864 or Form
I-864EZ. If you need more space to provide the
information, use Part 12. Additional Information. You
do not need to include any individual for whom your
sponsorship obligation has ended, that is, if you know
that: 1) the individual became a United States citizen, 2)
the individual is currently a lawful permanent resident
that has worked or can be credited with 40 qualifying
quarters of coverage, 3) the individual abandoned or lost
his or her lawful permanent resident status, 4) the
individual is deceased, or 5) the individual is obtaining a
new grant of adjustment of status while in removal
proceedings based on a new affidavit of support, if one is
required.
a. Sponsored Individual's Name
Date of Birth (mm/dd/yyyy)
Alien Registration Number
►
A-
3.
b.
c.
7.
Optional: If you have siblings, parents, or adult children
with the same principal residence who are combining
their income with yours by submitting Form I-864A, enter
the total number of people here:
►
8.
Add together Part 5., Item Numbers 1. - 7. and enter the
number here
►Household Size:
1
Form I-864 03/06/18 Page 5 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Part 7. Sponsor's Employment and Income
Name of Employer 1
1.
2.
I am currently:
Name of Employer 2 (if applicable)
3.
Employed as a/an
For
USCIS
Use
Only
Household Size
1
4
Remarks
Year: 2 0
Poverty Line:
Other
2
Poverty Guideline
$
3
5 6
7 8 9
4. Self-Employed as a/an (Occupation)
$
5. Retired Since (mm/dd/yyyy)
6.
Unemployed Since (mm/dd/yyyy)
7. My current individual annual income is:
Income you are using from any other individual who was
counted in your household size, including, in certain conditions,
the intending immigrant. (See Form I-864 Instructions.) Please
indicate name, relationship, and income.
8. Name
Person 1
9. Relationship
$Current Income10.
12.
13.
11. Name
$
Relationship
Current Income
Person 2
Name14.
Person 3
Relationship15.
Current Income
$16.
22.
One or more of the people listed in Item Numbers
8., 11., 14., and 17. do not need to complete Form
I-864A because he or she is the intending immigrant
and has no accompanying dependents.
Name
$
My Current Annual Household Income (Total all lines
from Part 7. Item Numbers 7., 10., 13., 16., and 19.; the
total will be compared to Federal Poverty Guidelines on
Form I-864P.)
20.
21. The people listed in Item Numbers 8., 11., 14., and
17. have completed Form I-864A. I am filing along
with this affidavit all necessary Form I-864As
completed by these people.
17.
18.
Name
Relationship
Person 4
19. $
Current Income
Federal Income Tax Return Information
Have you filed a Federal income tax return for each of the
three most recent tax years?
23.a.
NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
tax year.
No Yes
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
third most recent tax years.
23.b.
My total income as reported on my Federal income tax returns
for the most recent three years was:
Form I-864 03/06/18 Page 6 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
For
USCIS
Use
Only
Part 7. Sponsor's Employment and Income
(continued)
Household Size
1
4
Remarks
Year: 2 0
Poverty Line:
Other
2
Poverty Guideline
$
3
5 6
7 8 9
24.a.
24.b. 2nd Most Recent
3rd Most Recent
Most Recent
Total IncomeTax Year
24.c. $
$
$
I was not required to file a Federal income tax return
as my income was below the IRS required level and I
have attached evidence to support this.
25.
Credit Report Information (Optional)
26. I have attached a copy of a recent credit report.
1.
$
2. Enter the net cash value of real-estate holdings. (Net
value means current assessed value minus mortgage debt.)
$
If your income, or the total income for you and your household,
from Part 7., Item Numbers 20. or 24.a. - 24.c., exceeds the
Federal Poverty Guidelines for your household size, YOU ARE
NOT REQUIRED to complete this Part 8. Skip to Part 9.
Your Assets (Optional)
Enter the balance of all savings and checking accounts.
Part 8. Use of Assets to Supplement Income
(Optional)
Enter the net cash value of all stocks, bonds, certificates
of deposit, and any other assets not already included in
Item Number 1. or Item Number 2.
3.
$
Add together Item Numbers 1. - 3. and enter the number
here.
4.
$
TOTAL:
Assets from Form I-864A (Optional) If you need to provide
information about more than one Form I-864A, use the space
provided in Part 12. Additional Information.
Name of household member5.a.
Your household member's total assets from Form I-864A,
Part 4., Item Number 4.
$
5.b.
Enter the net cash value of all the principal immigrant's
real estate holdings. (Net value means investment value
minus mortgage debt.)
Enter the balance of the principal immigrant's savings and
checking accounts.
$
6.
Assets of the principal sponsored immigrant (Optional)
7.
$
Enter the current cash value of the principal immigrant's
stocks, bonds, certificates of deposit, and other assets not
included in Item Number 6. or Item Number 7.
8.
$
The principal sponsored immigrant is the individual listed in
Part 2., Item Numbers 1.a. - 1.c. Only include the assets if the
principal immigrant is being sponsored by this affidavit of
support.
9. Add together Item Numbers 6. - 8. and enter the number
here.
$
10. Add together Item Numbers 4., 5.b., and 9. and enter the
number here.
Total Value of Assets
$TOTAL:
Please note that, by signing this Form I-864, you agree to
assume certain specific obligations under the Immigration and
Nationality Act (INA) and other Federal laws. The following
paragraphs describe those obligations. Please read the
following information carefully before you sign Form I-864. If
you do not understand the obligations, you may wish to consult
an attorney or accredited representative.
NOTE: Read the Penalties section of the Form I-864
Instructions before completing this part.
Sponsor's Contract
Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
Form I-864 03/06/18 Page 7 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
What is the Legal Effect of My Signing Form I-864?
If you sign Form I-864 on behalf of any individual (called the
intending immigrant) who is applying for an immigrant visa or
for adjustment of status to that of a lawful permanent resident,
and that intending immigrant submits Form I-864 to the U.S.
Government with his or her application for an immigrant visa or
adjustment of status, under INA section 213A, these actions
create a contract between you and the U.S. Government. The
intending immigrant becoming a lawful permanent resident is
the consideration for the contract.
The U.S. Government cannot make you sign Form 1-864 if you
do not want to do so. But if you do not sign Form I-864, the
intending immigrant may not become a lawful permanent
resident in the United States.
What If I Choose Not to Sign Form I-864?
What Does Signing Form I-864 Require Me To Do?
If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864 that you have
signed, then you must do all of the following until your
obligations under this Form I-864 terminate:
A. Provide the intending immigrant any support
necessary to maintain him or her at an income that is
at least 125 percent of the Federal Poverty Guidelines
for your household size (100 percent if you are the
petitioning sponsor and are on active duty in the U.S.
Armed Forces or U.S. Coast Guard, and the intending
immigrant is your husband, wife, or unmarried child
under 21 years of age); and
Notify U.S. Citizenship and Immigration Services
(USCIS) of any change in your address, within 30
days of the change, by filing Form I-865.
B.
If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864 that you have signed,
then, until your obligations under Form I-864 terminate, the U.S.
Government may consider (deem) your income and assets as
available to that individual, in determining whether he or she is
eligible for certain Federal means-tested public benefits and also
for state or local means-tested public benefits, if the state or local
government's rules provide for consideration (deeming) of your
income and assets as available to the individual.
What Other Consequences Are There?
If you do not provide sufficient support to the individual who
becomes a lawful permanent resident based on a Form I-864
that you signed, that individual may sue you for this support.
What If I Do Not Fulfill My Obligations?
This provision does not apply to public benefits specified in
section 403(c) of the Welfare Reform Act such as emergency
Medicaid, short-term, non-cash emergency relief; services
provided under the National School Lunch and Child Nutrition
Acts; immunizations and testing and treatment for communicable
diseases; and means-tested public benefits under the Elementary
and Secondary Education Act.
If a Federal, state, local, or private agency provided any covered
means-tested public benefit to the person who becomes a lawful
permanent resident based on this Form I-864 that you signed,
you are responsible for reimbursing the agency for the amount
of the benefits they provided. If you do not make the
reimbursement, the agency may sue you for the amount that the
agency believes you owe. If you fail to reimburse the benefit
granting agency, you may become ineligible to sponsor anyone
in the future.
If you are sued, and the court enters a judgment against you, the
individual or agency that sued you may use any legally
permitted procedures for enforcing or collecting the judgment.
You may also be required to pay the costs of collection,
including attorney fees.
If you do not file a properly completed Form I-865 within 30
days of any change of address, USCIS may impose a civil fine
for your failing to do so.
When Will These Obligations End?
Your obligations under this Form I-864 will end if the
individual you are sponsoring who becomes a lawful permanent
resident based on the application for which this affidavit was
required:
Becomes a U.S. citizen;A.
Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;
B.
Has abandoned or lost lawful permanent resident
status and has departed the United States;
C.
Is subject to removal, but applies for and obtains, in
removal proceedings, a new grant of adjustment of
status, based on a new affidavit of support, if one is
required; or
D.
Dies.E.
Your obligations under this Form I-864 also end if you die.
Therefore, if you die, your estate is not required to take
responsibility for the individual's support after your death.
However, your estate may be required to reimburse a benefit
granting agency for any means-tested public benefits that the
intending immigrant received before you died.
Form I-864 03/06/18 Page 8 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
Sponsor's Statement
I can read and understand English, and I have read
and understand every question and instruction on this
affidavit and my answer to every question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.b. The interpreter named in Part 10. read to me every
question and instruction on this affidavit and my
answer to every question in
a language in which I am fluent, and I understood
everything.
,
2.
At my request, the preparer named in Part 11.,
prepared this affidavit for me based only upon
information I provided or authorized.
,
Sponsor's Daytime Telephone Number
Sponsor's Contact Information
3.
4.
5.
Sponsor's Mobile Telephone Number (if any)
Sponsor's Email Address (if any)
Sponsor's Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS or
the U.S. Department of State (DOS) may require that I submit
original documents to USCIS or DOS at a later date.
Furthermore, I authorize the release of any information from any
and all of my records that USCIS or DOS may need to determine
my eligibility for the benefit that I seek.
I furthermore authorize release of information contained in this
affidavit, in supporting documents, and in my USCIS or DOS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I understand that during the duration of my obligation
as a sponsor, I may be sued if the individuals named
in Part 3. receive means-tested benefits after
admission to the United States as immigrants or after
being granted adjustment of status;
D.
I understand that if the individual named in Part 3.
does apply for SNAP/Food Stamps, Supplemental
Security Income, Medicaid (other than Emergency
Medicaid) or Temporary Assistance for Needy
Families or other means-tested benefits, my own
income and assets may be considered in deciding the
individual's application. How long my income and
assets may be attributed to the individual named in
Part 3. is determined under the statutes and rules
governing each specific program;
E.
I understand that Form I-864 may be made available
to any Federal, State, or local agency that may
receive an application from the individuals named in
Part 3. for Supplemental Nutrition Assistance
Program (SNAP) benefits (formerly called Food
Stamps), Medicaid (other than Emergency Medicaid),
Supplemental Security Income, Temporary
Assistance to Needy Families, or other means-tested
benefits;
C.
I am willing and able to receive, maintain, and
provide support to the individual named in Part 3. at
the applicable threshold set forth in the Poverty
Guidelines and by statute;
B.
I have read the section entitled Sponsor and
Beneficiary Liability in the Instructions for this
affidavit, and am aware of my responsibilities as a
sponsor under the Social Security Act, as amended,
and the Food Stamp Act, as amended;
G.
Each of the Federal income tax returns submitted in
support of this affidavit are true copies, or are
unaltered tax transcripts, of the tax returns I filed
with the IRS;
I. I understand that, if I am related to the sponsored
immigrant by marriage, the termination of the
marriage (by divorce, dissolution, annulment, or
other legal process) will not relieve me of my
obligations under this Form I-864;
H.
I agree to submit to the personal jurisdiction of any
Federal state, or local court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864;
F.
I certify, under penalty of perjury, that:
I provided or authorized all of the information in my
affidavit, I understand all of the information
contained in, and submitted with, my affidavit, and
that all of this information is complete, true, and
correct;
A.
NOTE: Divorce does not terminate your obligations under
Form I-864.
Form I-864 03/06/18 Page 9 of 12
DRAFT
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03/31/2020
Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
K.
I authorize agencies and entities that administer or
oversee means-tested public benefits, and any agency
or entity that is authorized to act on its behalf, to
disclose information to the Department of Homeland
Security (DHS) and Department of State (DOS), for
the purpose of administration of federal laws
regarding my obligations as a sponsor, as agreed to in
this affidavit and only as permitted by law. If any
alien that I sponsor on this affidavit applies for a
means-tested public benefit, including Medicaid, the
Children's Health Insurance Program, Temporary
Assistance to Needy Families, or the Supplemental
Nutrition Assistance Program, or any other Federal or
State public benefit subject to deeming of my income
and/or assets/resources or for which I could be liable
for reimbursement, I specifically authorize the
agencies and entities that administer or oversee
means-tested public benefits, and any agency or
entity that is authorized to act on its behalf, to
disclose my name, Social Security number, date of
birth, information about the agency's deeming of my
income and/or assets/resources, and any
reimbursement obligations to DHS and DOS. This
consent is valid for the entire period of enforceability
of my obligations as a sponsor.
I understand that the information that agencies and
entities that administer or oversee means-tested
public benefits, and any agency or entity that is
authorized to act on its behalf, disclose to DHS and
DOS is for official use only to administer federal
laws regarding my support obligations as a sponsor,
and that DHS and DOS may disclose my information
only as authorized by law;
L.
I understand that I may be subject to a civil penalty if
I fail to notify U.S. Citizenship and Immigration
Services (USCIS) of any change in my address,
within 30 days of the change, by filing Form I-865,
Sponsor's Notice of Change of Address;
I understand that if I fail to respond within 45 days to
a request for reimbursement from a public benefit-
granting agency or an appropriate government entity
because the individual named in Part 3. received a
means-tested benefit, an action may be brought
against me pursuant to the affidavit of support;
J.
Sponsor's Signature
Date of Signature (mm/dd/yyyy)6.b.
Sponsor's Signature6.a.
Subscribed and sworn to (or affirmed) before me this
day of
(Month), (Year) at
,
My commission expires on (mm/dd/yyyy)
Signature of Notary Public
NOTE TO ALL SPONSORS: If you do not completely fill
out this affidavit or fail to submit required documents listed in
the Instructions, USCIS or DOS may deny your affidavit.
I authorize the Social Security Administration (SSA)
to disclose information to DHS and DOS, for the
purpose of administration of federal laws regarding
my obligations as a sponsor, as agreed to in this
affidavit and only as permitted by law. If any alien
that I sponsor on this affidavit applies for
Supplemental Security Income payments, I
specifically authorize SSA to disclose my name,
Social Security number, date of birth, the deeming of
my income and/or assets/resources, and my
reimbursement obligations to DHS and DOS. This
consent is valid for the entire period of enforceability
of my obligations as a sponsor. I understand that the
information SSA discloses to DHS and DOS is for
official use for the purpose of administration of
federal laws regarding my obligation as a sponsor
and that DHS and DOS may disclose my information
as authorized by law; and
N. I acknowledge that if I fail to meet the obligations of
sponsorship, I may become ineligible to sponsor
anyone in the future.
M.
Notary Public Stamp
Form I-864 03/06/18 Page 10 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
3.g.
Province
Street Number and Name3.a.
Country
3.b.
Flr.
Ste.Apt.
Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
5. Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
which is the same language specified in Part 8., Item Number
1.b., and I have read to this sponsor in the identified language
every question and instruction on this affidavit and his or her
answer to every question. The sponsor informed me that he or
she understands every instruction, question, and answer on the
affidavit, including the Sponsor's Certification, and has
verified the accuracy of every answer.
I am fluent in English and
,
Interpreter's Business or Organization Name (if any)2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information about the interpreter.
Part 10. Interpreter's Contact Information,
Certification, and Signature
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Part 11. Contact Information, Certificaition, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number and Name3.a.
3.b. Flr.Ste.Apt.
3.h.
3.f.
Postal Code 3.g.
Country
Province
Part 10. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
Form I-864 03/06/18 Page 11 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
I am an attorney or accredited representative and my
representation of the sponsor in this case
7.b.
extends does not extend beyond the
preparation of this affidavit.
NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, or G-28I,
Notice of Entry of Appearance as Attorney In
Matters Outside the Geographical Confines of the
United States, with this affidavit.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this affidavit at the request of the sponsor. The sponsor
then reviewed this completed affidavit and informed me that he
or she understands all of the information contained in, and
submitted with, his or her affidavit, including the Sponsor's
Certification, and that all of this information is complete, true,
and correct. I completed this affidavit based only on information
that the sponsor provided to me or authorized me to obtain or use.
Preparer's Signature
I am not an attorney or accredited representative but
have prepared this affidavit on behalf of the sponsor
and with the sponsor's consent.
7.a.
Preparer's Statement
6. Preparer's Email Address (if any)
Form I-864 03/06/18 Page 12 of 12
DRAFT
NOT FOR
PRODUCTION
03/31/2020
3.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
Part 12. Additional Information
If you need extra space to provide any additional information
within this affidavit, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this affidavit or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. A-Number (if any)
3.a. Page Number 3.b. Part Number 3.c. Item Number
A-
►
4.d.
4.a.
Page Number 4.b. Part Number 4.c. Item Number
5.a.
Page Number 5.b. Part Number 5.c. Item Number
5.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
7.d.
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20041030d Form I-864, Affidavit of Support Under Section 213A of the INA

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Completed 10 July 2020

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