Fillable Form G-28 or: Request for Exemption for Intending (USCIS)

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Form G-28 or: Request for Exemption for Intending (USCIS)

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-864W Edition 03/10/21 Page 1 of 5
Request for Exemption for Intending Immigrant's Affidavit
of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-864W
OMB No. 1615-0075
Expires 09/30/2021
START HERE - Type or print in black ink.►
This Form I-864W:
DOES NOT MEET
the requirements of
exemption
MEETS the
requirements of
exemption
For Government Use Only
Date (mm/dd/yyyy):
Reviewed By:
Location:
To be completed by an
attorney or accredited
representative (if any).
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.
Part 1. Information About You or Your Adopted
Child (Intending Immigrant)
Name of Requestor
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Mailing Address
2.a. In Care Of Name
Street Number
and Name
2.b.
2.c. Apt.
Flr.Ste.
2.d. City or Town
2.g. Province
2.i. Country
2.e.
State
2.f.
ZIP Code
2.h.
Postal Code
Is your current mailing address the same as your physical
address?
No Yes
If you answered "No" to Item Number 3., provide your
physical address.
3.
Physical Address
4.c. City or Town
4.d.
State
4.e.
ZIP Code
Country4.h.
4.f.
Province
Postal Code4.g.
Street Number
and Name
4.a.
4.b. Apt.
Flr.Ste.
Other Information
Date of Birth (mm/dd/yyyy)
5.
8.
City or Town of Birth
6.
State or Province of Birth
(if applicable)
7.
Country of Birth
Alien Registration Number (A-Number)
►
A-
9.
►
U.S. Social Security Number (Required)
11.
USCIS Online Account Number (if any)
►
10.
(USPS ZIP Code Lookup)
Form I-864W Edition 03/10/21 Page 2 of 5
Part 2. Reason for Exemption
I am EXEMPT from filing Form I-864, Affidavit of Support
Under Section 213A of the INA, because:
1.a.
1.b.
I have earned (or can be credited with) 40 quarters
(credits) of coverage under the Social Security Act
(SSA). (Attach SSA earnings statements. Do not
count any quarters during which you received a
means-tested public benefit.)
I am under 18 years of age, unmarried, immigrating
as the child of a U.S. citizen, and will automatically
become a U.S. citizen under the Child Citizenship
Act of 2000 upon my admission to the United States.
1.c.
I am filing for an immigrant visa or adjustment of
status as a self-petitioning widow(er) using Form
I-360, Petition for Amerasian, Widow(er), or Special
Immigrant.
1.d.
I am filing for an immigrant visa or adjustment of
status as a battered spouse or child using Form I-360.
Part 3. Requestor's (Intending Immigrant's)
Contract, Statement, Contact Information,
Declaration, Certification, and Signature
NOTE: Read the Penalties section of the Form I-864W
Instructions before completing this part.
Requestor's Statement
1.b. The interpreter named in Part 4. read to me every
question and instruction on this request and my
answer to every question in
a language in which I am fluent, and I understood
everything.
,
I can read and understand English, and I have read
and understand every question and instruction on this
request 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.
2.
At my request, the preparer named in Part 5.,
,
prepared this request for me based only upon
information I provided or authorized.
Requestor's Contact Information
Requestor's Daytime Telephone Number
3.
4.
5.
Requestor's Mobile Telephone Number (if any)
Requestor's Email Address (if any)
Requestor's Declaration and Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that U.S. Citizenship and Immigration Services (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 immigration benefit that I seek.
I furthermore authorize release of information contained in this
request, 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 request 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 request, and
that all of this information is complete, true, and correct.
In addition, I authorize the Social Security Administration
(SSA) to release information about me in its records to USCIS
and DOS.
Requestor's Signature
Date of Signature (mm/dd/yyyy)
6.a. Requestor's Signature
6.b.
NOTE TO ALL REQUESTORS: If you do not completely
fill out this request or fail to submit required documents listed
in the Instructions, USCIS or DOS may deny your request.
Form I-864W Edition 03/10/21 Page 3 of 5
Part 4. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
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 Name
3.a.
Country
3.b. Apt.
Flr.Ste.
Postal Code
which is the same language specified in Part 3., Item Number
1.b., and I have read to this requestor in the identified language
every question and instruction on this request and his or her
answer to every question. The requestor informed me that he or
she understands every instruction, question, and answer on the
request, including the Requestor's Declaration and
Certification, and has verified the accuracy of every answer.
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
5. Interpreter's Mobile Telephone Number (if any)
Interpreter's Signature
(mm/dd/yyyy)Date of Signature7.b.
Interpreter's Signature7.a.
Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor
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.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f.
Postal Code 3.g.
Country
Province
6. Preparer's Email Address (if any)
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
Form I-864W Edition 03/10/21 Page 4 of 5
I am not an attorney or accredited representative but
have prepared this request on behalf of the requestor
and with the requestor's consent.
I am an attorney or accredited representative and my
representation of the requestor in this case
7.a.
7.b.
Preparer's Statement
extends does not extend beyond the
preparation of this request.
NOTE: If you are an attorney or accredited representative you
may be obliged 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 request.
Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor (continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this request at the request of the requestor. The
requestor then reviewed this completed request and informed
me that he or she understands all of the information contained
in, and submitted with, his or her request, including the
Requestor's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
request based only on information that the requestor provided to
me or authorized me to obtain or use.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Form I-864W Edition 03/10/21 Page 5 of 5
3.d.
5.d.
Part 6. Additional Information
If you need extra space to provide any additional information
within this request, 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 request 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
5.a.
Page Number 5.b. Part Number 5.c. Item Number
A-
4.d.
4.a. Page Number 4.b. Part Number 4.c. Item Number
6.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
7.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
►
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Form G-28 or: Request for Exemption for Intending (USCIS)

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Completed 31 March 2021

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