Form I-864 Edition 03/10/21
Page 7 of 10
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 a Form I-864 that you signed, the
agency may ask you to reimburse them 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
If you are sued, and the court enters a judgment against you, the
person 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
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.
The interpreter named in Part 9. 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
At my request, the preparer named in Part 10.,
prepared this affidavit for me based only upon
information I provided or authorized.
When Will These Obligations End?
Your obligations under a Form I-864 that you signed will end if
the person who becomes a lawful permanent resident based on
Sponsor's Daytime Telephone Number
Sponsor's Contact Information
Sponsor's Mobile Telephone Number (if any)
Sponsor's Email Address (if any)
Becomes a U.S. citizen;A.
Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;
No longer has lawful permanent resident status and
has departed the United States;
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
NOTE: Divorce does not terminate your obligations under
Your obligations under a Form I-864 that you signed also end if
you die. Therefore, if you die, your estate is not required to
take responsibility for the person's support after your death.
However, your estate may owe any support that you
accumulated before you died.
Sponsor's Declaration and 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 certify, under penalty of perjury, that all of the information in
my affidavit and any document submitted with it were provided
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my affidavit and
that all of this information is complete, true, and correct.
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.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
I know the contents of this affidavit of support that I
I agree to submit to the personal jurisdiction of any
Federal or state court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864;
I have read and I understand each of the obligations
described in Part 8., and I agree, freely and without
any mental reservation or purpose of evasion, to
accept each of those obligations in order to make it
possible for the immigrants indicated in Part 3. to
become lawful permanent residents of the United
Part 8. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and