Fillable I-864ez Form I-864EZ, Affidavit of Support Under Section 213A of the INA

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I-864ez Form I-864EZ, Affidavit of Support Under Section 213A of the INA

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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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Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-864EZ
OMB No. 1615-0075
Expires 03/31/2020
START HERE - Type or print in black ink.►
Part 1. Qualifying to Use Form I-864EZ
I am the petitioner of the family member sponsored on
this affidavit.
I am using my own earned or retirement income, which is
documented using Internal Revenue Service (IRS) Form
W-2.
1.c.
The sponsored immigrant is the only person immigrating
based on the underlying visa petition.
1.b.
1.a.
Part 2. Information About the Immigrant You
Are Sponsoring (Intending Immigrant)
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Date of Birth (mm/dd/yyyy)4.
Alien Registration Number (A-Number) (if any)
6.
►
A-
USCIS Online Account Number (if any)
7.
►
No (Use Form I-864)Yes
No (Use Form I-864)
Yes
No (Use Form I-864)Yes
Mailing Address
►
U.S. Social Security Number (if any)
5.
This Form I-864EZ:
DOES NOT MEET
the requirements of
INA section 213A
MEETS the
requirements of
INA section 213A
For Government Use Only
Date (mm/dd/yyyy):
Reviewed By:
Location:
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
Other Information
Daytime Telephone Number3.
Name of Immigrant
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.
Form I-864EZ 03/06/18 Page 1 of 7
(USPS ZIP Code Lookup)
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
Given Name
(First Name)
Part 3. Information About You (Sponsor)
1.a. Family Name
(Last Name)
1.b.
1.c.
Middle Name
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 below.
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
Country of Domicile
Date of Birth (mm/dd/yyyy)
5.
►
U.S. Social Security Number (Required)
10.
9.
6.
City or Town of Birth
7.
State or Province of Birth
(if applicable)
8.
Country of Birth
USCIS Online Account Number (if any)
►
11.
12.
13.a.
Citizenship or Nationality
I am a U.S. citizen.
I am a U.S. national.
I am a lawful permanent resident.
My alien registration number is:
►
A-
13.b.
14.
No Yes
I am currently on active duty in the United States Armed
Forces or U.S. Coast Guard.
Military Service
15.
If you have sponsored any other persons on a Form I-864
who are now lawful permanent residents in the United
States, enter the number here.
1.d.
If you have any other dependents listed on your most
recent Federal income tax return, enter the number here.
1.e.
Your dependent children under 21 years of age.1.c.
Your spouse.1.b.
Part 4. Information About Your Household Size
NOTE: Do not count any household member more than once.
1.a. Yourself and the person you are sponsoring on this Form
I-864EZ.
Add together Item Numbers 1.a. - 1.e. and enter the
number here. This is your HOUSEHOLD SIZE for the
purpose of this Form I-864EZ.
1.f.
Form I-864EZ 03/06/18 Page 2 of 7
Current Occupation
Name of Employer 1
Name of Employer 2 (if applicable)
Name of Former Employer
Date of Retirement (mm/dd/yyyy)
1.
3.a.
Part 5. Information About Your Employment
and Income
2.a.
2.b.
I am currently:
Retired (Complete Item Numbers 3.a. - 3.b.)
Employed (Complete Item Numbers 2.a. - 2.c.)
2.c.
3.b.
My current individual annual income
4. $
Federal Income Tax Information
Have you filed a Federal income tax return for each of the
three most recent tax years?
My total income (adjusted gross income on IRS Form 1040EZ)
as reported on my Federal income tax returns for the most recent
three years was:
5.a.
NOTE: You MUST attach a photocopy or transcript
of your Federal income tax return for only the most
recent tax year.
No Yes
6.a.
6.b.
2nd Most Recent
3rd Most Recent
Most Recent
Total Income
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
third most recent tax years.
5.b.
Tax Year
6.c. $
$
$
Part 6. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-864EZ
Instructions before completing this part.
By signing this Form I-864EZ, 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-864EZ. If you do not understand the obligations, you may
wish to consult an attorney or accredited representative.
What Is the Legal Effect of Signing Form
I-864EZ?
If you sign Form I-864EZ on behalf of any person (intending
immigrant) who is applying for an immigrant visa or adjustment
of status to a lawful permanent resident, and that intending
immigrant submits Form I-864EZ 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.
You cannot be made to sign Form I-864EZ if you do not want
to do so. But if you do not sign Form I-864EZ, the intending
immigrant may not be able to become a lawful permanent
resident in the United States.
What If I Choose Not to Sign Form I-864EZ?
If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864EZ that you have
signed, then, until your obligations under Form I-864EZ
terminate, you must:
What Does Signing Form I-864EZ Require Me to
Do?
Under this contract, you agree that, in deciding whether the
intending immigrant can establish that he or she is not
inadmissible to the United States as a foreign national likely to
become a public charge, the U.S. Government can consider
your income and assets available for the support of the
intending immigrant.
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 his or her household size (or 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 person is your husband, wife, or
unmarried child under 21 years of age.); and
A.
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. Please
see the USCIS website at www.uscis.gov/I-865 for
more information on filing a change of address as a
sponsor.
B.
Form I-864EZ 03/06/18 Page 3 of 7
What Other Consequences Are There?
If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864EZ that you have
signed, then, until your obligations under Form I-864EZ
terminate, your income and assets may be considered available
to that person, 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 of your income
and assets as available to the person.
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 programs under the
Elementary and Secondary Education Act.
Part 6. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
If a Federal, state, local, or a private agency provides any
covered means-tested public benefit to the person who becomes
a lawful permanent resident based on the Form I-864EZ 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 you owe.
If you do not provide sufficient support to the person who
becomes a lawful permanent resident based on the Form
I-864EZ that you signed, that person may sue you for this
support.
What If I Do Not Fulfill My Obligations?
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. Please see the USCIS website at
www.uscis.gov/I-865 for more information on filing a change
of address as a sponsor.
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
attorney fees.
No longer has lawful permanent resident status and
has departed the United States;
C.
Becomes 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.
Becomes a U.S. citizen;A.
Has worked, or can receive credit for 40 quarters of
coverage under the Social Security Act (SSA);
B.
Your obligations under Form I-864EZ also end if you die.
Therefore, if you die, your estate will not be required to take
responsibility for the person's support after your death. Your
estate may, however, be responsible for any support that you
owed before you died.
NOTE: Divorce does not terminate your obligations
under this Form I-864EZ.
Sponsor's Statement
1.b.
The interpreter named in Part 7. 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.
,
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.
2.
At my request, the preparer named in Part 8.,
,
prepared this affidavit for me based only upon
information I provided or authorized.
Your obligations under Form I-864EZ will end if the person
who becomes a lawful permanent resident based on a Form
I-864EZ that you signed:
When Will These Obligations End?
Sponsor's Contact Information
Sponsor's Daytime Telephone Number
3.
4.
5.
Sponsor's Mobile Telephone Number (if any)
Sponsor's Email Address (if any)
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 of my records that USCIS or DOS may need to
determine my eligibility for the immigration benefit I seek.
Form I-864EZ 03/06/18 Page 4 of 7
Part 6. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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 have read and I understand each of the obligations
described in Part 6., 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 immigrant indicated in Part 2. to
become a lawful permanent resident of the United
States;
B.
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-864EZ;
C.
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;
D.
A. I know the contents of this affidavit of support that I
signed;
I authorize the Social Security Administration to
release information about me in its records to the
USCIS and DOS.
F.
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-864EZ; and
E.
Sponsor's Signature
(mm/dd/yyyy)Date of Signature
6.a. Sponsor's Signature
6.b.
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 request.
Part 7. 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 6., 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 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)
Form I-864EZ 03/06/18 Page 5 of 7
Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Signature
(mm/dd/yyyy)Date of Signature7.b.
Interpreter's Signature7.a.
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor
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)
I am not an attorney or accredited representative but
have prepared this affidavit on behalf of the sponsor
and with the sponsor's consent.
I am an attorney or accredited representative and my
representation of the sponsor in this case
7.a.
7.b.
Preparer's Statement
extends does not extend beyond the
preparation of this affidavit.
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 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 Declaration and 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
Form I-864EZ 03/06/18 Page 6 of 7
3.d.
5.d.
Part 9. 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
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
►
Form I-864EZ 03/06/18 Page 7 of 7
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I-864ez Form I-864EZ, Affidavit of Support Under Section 213A of the INA

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Completed 17 November 2019

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