Fillable Ins-form-i-864 Form I-864, Affidavit of Support Under Section 213A of the INA

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Ins-form-i-864 Form I-864, Affidavit of Support Under Section 213A of the INA

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Form I-864 10/15/19
Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services
Page 1 of 10
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 Name
2.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.
Apt. Flr.Ste.
Affidavit of Support Submitter
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.
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)5.
►
A-
USCIS Online Account Number (if any)6.
►
3. Country of Citizenship or Nationality
Other Information
Date of Birth (mm/dd/yyyy)4.
Daytime Telephone Number
7.
USCIS
Form I-864
OMB No. 1615-0075
Expires 10/31/2021
For
USCIS
Use
Only
(USPS ZIP Code Lookup)
Form I-864 10/15/19
Page 2 of 10
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
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
11. Date of Birth (mm/dd/yyyy)
Relationship to Principal Immigrant10.
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)
27. Alien Registration Number (A-Number) (if any)
►
A-
USCIS Online Account Number (if any)28.
►
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.
Form I-864 10/15/19
Page 3 of 10
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 Name
2.b.
2.c.
Apt. Flr.Ste.
Province2.g.
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 Name
4.a.
4.b.
Apt. Flr.Ste.
4.f. Province
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
or U.S. Coast Guard.
14.
NoYes
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 11. Additional Information.
Do not count the principal immigrant if you are only
sponsoring family members entering more than 6 months
after the principal immigrant.
Part 3. Information About the Immigrants You
Are Sponsoring (continued)
Form I-864 10/15/19
Page 4 of 10
For
USCIS
Use
Only
Part 5. Sponsor's Household Size
NOTE: Do not count any member of your household more
than once.
Persons 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 number here.
If you are currently married, enter "1" for your spouse.
Yourself.
Persons NOT sponsored in this affidavit:
5.
6.
If you have any other dependents, enter the number here.
If you have sponsored any other persons on Form I-864 or
Form I-864EZ who are now lawful permanent residents,
enter the number here.
Add together Part 5., Item Numbers 1. - 7. and enter the
number here.
8.
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 number here.
Household Size:
Part 6. Sponsor's Employment and Income
Name of Employer 1
1.
2.
I am currently:
Name of Employer 2 (if applicable)
3.
4.
Income you are using from any other person 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.
Name14.
Name
$
Relationship
Current Income
Person 2
Person 3
Relationship15.
Current Income
$16.
17.
18.
Name
Relationship
Person 4
19. $
Current Income
Employed as a/an
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:
Form I-864 10/15/19
Page 5 of 10
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.
Your household member's assets from Form I-864A
(optional).
Add together Item Numbers 1. - 3. and enter the number
here.
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.
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
Federal Income Tax Return Information
Household Size
1
4
Remarks
Year: 2 0
Poverty Line:
Other
2
Poverty Guideline
$
3
5 6
7 8 9
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.
Have you filed a Federal income tax return for each of the
three most recent tax years?
My total income (adjusted gross income on Internal Revenue
Service (IRS) Form 1040EZ) as reported on my Federal income
tax returns for the most recent three years was:
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
24.a.
24.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.
23.b.
Tax Year
24.c. $
$
$
25.
1.
$
2.
3.
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 6., 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 7. Skip to Part 8.
Your Assets (Optional)
Enter the balance of all savings and checking accounts.
4.
$TOTAL:
$
$
Assets from Form I-864A, Part 4., Item Number 3.d., for:
Name of Relative
5.b.
5.a.
6.
Assets of the principal sponsored immigrant (optional).
$
My Current Annual Household Income (Total all lines
from Part 6. 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.
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.
$
Part 6. Sponsor's Employment and Income
(continued)
Part 7. Use of Assets to Supplement Income
(Optional)
The principal sponsored immigrant is the person 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.
For
USCIS
Use
Only
Form I-864 10/15/19
Page 6 of 10
9.
10. Add together Item Numbers 4., 5.b., and 9. and enter the
number here.
Total Value of Assets
Add together Item Numbers 6. - 8. and enter the number
here.
$
$TOTAL:
Household Size
1
4
For
USCIS
Use
Only
Remarks
Year: 2 0
Poverty Line:
Other
2
Poverty Guideline
$
3
5 6
7 8 9
The total value of all assets, line 10, must equal 5 times (3 times for spouses and children of
USC's, or 1 time for orphans to be formally adopted in the U.S.) the difference between the
poverty guidelines and the sponsor's household income, line 10.
Sponsor's Household Income
(Page 5, Line 10)
$
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.
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, until your obligations under Form I-864 terminate,
you must:
NOTE: Read the Penalties section of the Form I-864
Instructions before completing this part.
Sponsor's Contract
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 his or her 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
person 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.
What is the Legal Effect of My Signing Form I-864?
If you sign Form I-864 on behalf of any person (called the
intending immigrant) who is applying for an immigrant visa or
for adjustment of status to 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.
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 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
(deeming) of your income and assets as available to the person.
What Other Consequences Are There?
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 person likely to become a
public charge, the U.S. Government can consider your income
and assets as available for the support of the intending
immigrant.
If you do not provide sufficient support to the person who
becomes a lawful permanent resident based on a Form I-864
that you signed, that person may sue you for this support.
What If I Do Not Fulfill My Obligations?
Part 7. Use of Assets to Supplement Income
(Optional) (continued)
Part 8. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature
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.
Form I-864 10/15/19
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
you owe.
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.
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.
1.b.
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
everything.
,
2.
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
that affidavit:
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)
Becomes a U.S. citizen;A.
Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;
B.
No longer has 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.
NOTE: Divorce does not terminate your obligations under
Form I-864.
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.
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.
I know the contents of this affidavit of support that I
signed;
A.
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;
C.
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
States;
B.
Part 8. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Form I-864 10/15/19
Page 8 of 10
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.
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; and
E.
F. I authorize the Social Security Administration to
release information about me in its records to
USCIS and DOS.
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
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)
Sponsor's Signature
Date of Signature (mm/dd/yyyy)6.b.
Sponsor's Signature6.a.
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.
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 Declaration and
Certification, and has verified the accuracy of every answer.
I am fluent in English and
,
Interpreter's Given Name (First Name)1.b.
Provide the following information about the interpreter.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Interpreter's Business or Organization Name (if any)2.
Part 8. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Part 9. Interpreter's Contact Information,
Certification, and Signature
Form I-864 10/15/19
Page 9 of 10
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.
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)
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
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
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 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
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor
Form I-864 10/15/19
Page 10 of 10
3.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
Part 11. 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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Ins-form-i-864 Form I-864, Affidavit of Support Under Section 213A of the INA

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Completed 2 July 2020

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