Blank USCIS I-864 Template

For

USCIS

Use

Only

Affidavit of Support Submitter

Petitioner

1st Joint Sponsor

2nd Joint Sponsor

Substitute Sponsor

5% Owner

Section 213A Review

Date (mm/dd/yyyy):

Number of Support Affidavits in File

Remarks

►START HERE - Type or print in black ink.

Part 1. Basis For Filing Affidavit of Support

am the sponsor submitting this affidavit of support because (Select only one box):

2.a. In Care Of Name

2.b. Street Number

and Name

2.c. Apt. Ste. Flr.

2.d. City or Town

2.e. State

2.g. Province

2.h. Postal Code 2.i. Country

2.f. ZIP Code

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.

Other Information

3.Country of Citizenship or Nationality

4.Date of Birth (mm/dd/yyyy)

5.Alien Registration Number (A-Number) (if any)

►A-

Part 2. Information About the Principal Immigrant

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

6.USCIS Online Account Number (if any)

►

7.Daytime Telephone Number

Part 3. Information About the Immigrants You Are Sponsoring

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.)

3. I am sponsoring the following family members who are immigrating more than six months after the principal immigrant.

Family Member 1

4.a. Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

5.Relationship to Principal Immigrant

6. Date of Birth (mm/dd/yyyy)

7.Alien Registration Number (A-Number) (if any)

► A-

8.USCIS Online Account Number (if any)

►

Family Member 2

9.a. Family Name

(Last Name)

9.b. Given Name

(First Name)

9.c. Middle Name

10.Relationship to Principal Immigrant

11. Date of Birth (mm/dd/yyyy)

12.Alien Registration Number (A-Number) (if any)

► A-

13.USCIS Online Account Number (if any)

►

Family Member 3

14.a. Family Name

(Last Name)

14.b. Given Name

(First Name)

14.c. Middle Name

15.Relationship to Principal Immigrant

16.Date of Birth (mm/dd/yyyy)

17.Alien Registration Number (A-Number) (if any)

► A-

18.USCIS Online Account Number (if any)

►

Family Member 4

19.a. Family Name

(Last Name)

19.b. Given Name

(First Name)

19.c. Middle Name

20.Relationship to Principal Immigrant

21.Date of Birth (mm/dd/yyyy)

22.Alien Registration Number (A-Number) (if any)

► A-

23.USCIS Online Account Number (if any)

►

Family Member 5

24.a. Family Name

(Last Name)

24.b. Given Name

(First Name)

24.c. Middle Name

25.Relationship to Principal Immigrant

26.Date of Birth (mm/dd/yyyy)

27.Alien Registration Number (A-Number) (if any)

► A-

28.USCIS Online Account Number (if any)

►

Part 3. Information About the Immigrants You Are Sponsoring (continued)

Sponsor's Physical Address

4.a. Street Number

and Name

4.b. Apt. Ste. Flr.

4.c. City or Town

Part 4. Information About You (Sponsor)

Sponsor's Full Name

4.d. State

4.f. Province

4.g. Postal Code

4.h. Country

4.e. ZIP Code

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

Sponsor's Mailing Address

2.a. In Care Of Name

2.b. Street Number

and Name

2.c. Apt. Ste. Flr.

2.d. City or Town

2.g. Province

2.h. Postal Code

2.i. Country

3.Is your current mailing address the same as your physical

If you answered "No" to Item Number 3., provide your physical address in Item Numbers 4.a. - 4.h.

Other Information

5.Country of Domicile

6. Date of Birth (mm/dd/yyyy)

7.City or Town of Birth

8.State or Province of Birth

9.Country of Birth

10.U.S. Social Security Number (Required)

12.Sponsor's A-Number (if any)

► A-

13.Sponsor's USCIS Online Account Number (if any)

►

Military Service (To be completed by petitioner sponsors only.)

14.I am currently on active duty in the U.S. Armed Forces

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:

5.

6.

Retired Since (mm/dd/yyyy)

Unemployed Since (mm/dd/yyyy)

1.Provide the number you entered in Part 3., Item Number

29.

Persons NOT sponsored in this affidavit:

2. Yourself.

3.If you are currently married, enter "1" for your spouse.

4.If you have dependent children, enter the number here.

5.If you have any other dependents, enter the number here.

6.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.

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.

8.Add together Part 5., Item Numbers 1. - 7. and enter the number here.

Household Size:

Part 6. Sponsor's Employment and Income

I am currently:

1. Employed as a/an

2.Name of Employer 1

7.My current individual annual income is:

$

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.

Person 1

8.Name

9.Relationship

Person 3

14.Name

15.Relationship

Person 4

4.

For

USCIS

Use

Only

Household Size

1 2 3

4 5 6

7 8 9

Other

Poverty Guideline

Year: 2 0

Poverty Line:

$

Remarks

Part 6. Sponsor's Employment and Income

(continued)

20.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

17.have completed Form I-864A. I am filing along with this affidavit all necessary Form I-864As completed by these people.

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

23.a. Have you filed a Federal income tax return for each of the

NOTE: You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year.

23.b. (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third 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:

25. 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.

Part 7. Use of Assets to Supplement Income

(Optional)

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)

1.Enter the balance of all savings and checking accounts.

$

2.Enter the net cash value of real-estate holdings. (Net value means current assessed value minus mortgage debt.)

$

3.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.

$

4.Add together Item Numbers 1. - 3. and enter the number

Assets from Form I-864A, Part 4., Item Number 3.d., for:

5.a. Name of Relative

5.b. Your household member's assets from Form I-864A

(optional).$

Assets of the principal sponsored immigrant (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.

6.Enter the balance of the principal immigrant's savings and

7.Enter the net cash value of all the principal immigrant's real estate holdings. (Net value means investment value

8.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.

$

Part 8. Sponsor's Contract, Statement, Contact

Information, Declaration, Certification, and

Signature

NOTE: Read the Penalties section of the Form I-864 Instructions before completing this part.

Sponsor's Contract

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.

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.

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.

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

B.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.

What Other Consequences Are There?

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.

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.

What If I Do Not Fulfill My Obligations?

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.

Part 8. Sponsor's Contract, Statement, Contact

Information, Declaration, Certification, and

Signature (continued)

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.

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:

A.Becomes a U.S. citizen;

B.Has worked, or can receive credit for, 40 quarters of coverage under the Social Security Act;

C.No longer has lawful permanent resident status and has departed the United States;

D.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

E.Dies.

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 Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

Sponsor's Contact Information

3.Sponsor's Daytime Telephone Number

4.Sponsor's Mobile Telephone Number (if any)

5.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 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.

A.I know the contents of this affidavit of support that I signed;

B.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;

C.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;

Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and

Signature (continued)

Interpreter's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

3.e. ZIP Code

Sponsor's Signature

6.a. Sponsor's Signature

6.b. Date of Signature (mm/dd/yyyy)

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.

Part 9. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.Interpreter's Business or Organization Name (if any)

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (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 Declaration and Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Affidavit, if Other Than the Sponsor

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

Preparer's Statement

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.

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

3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

3.e. ZIP Code

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

8.a. Preparer's Signature

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

8.b. Date of Signature (mm/dd/yyyy)

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)

► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.