I-864 W Intending Immigrant�s Affidavit of Support Exemption

OMB No. 1615-0075; Expires 10/31/07

I-864W, Intending Immigrant's
Affidavit of Support Exemption

Department of Homeland Security
U.S. Citizenship and Immigration Services

Instructions
How Should I Complete This Form?
Print clearly or type your answers using CAPITAL letters.
Use black or blue ink.

If you are claiming credit for quarters worked by a spouse or
parent, you may not count any quarter in which the spouse or
parent was receiving means-tested public benefits. Include all
SSA forms necessary to establish that you have or can be
credited with 40 quarters of coverage.

If you need extra spact to answer any item:
-- Attach a seperate sheet of paper (or more sheets if
necessary); and
-- Write your name, Social Security number and the
words "Form I-864W" on the top right corner of the
sheet; and write the number and subject of each
question for which you are providing additional
information.

What Is the Purpose of This Form?
The Form I-864 is legally required for many family-based
immigrants and some employment-based immigrants to show
that they have adequate means of financial support and that
they are not likely to become a public charge. Certain classes
of immigrants are exempt from the I-864 requirement and
therefore must file Form I-864W instead of Form I-864 or
Form I-864EZ. For more information abut Forms I-864,
I-864EZ, or I-864W, or to obtain related forms please contact:
The USCIS Website (www.uscis.gov);
The National Customer Service Center (NCSC) telephone
line at 1-800-375-5283 TTY: (1-800-767-1833); or
Your local USCIS office by using InfoPass.

How Is This Form Used?
You must use this form instead of Form I-864 with your
application for an immigrant visa or adjustment of status if
any of the following apply:
(1) You have earned (or can be credited with) 40 quarters
of coverage under the Social Security Act (SSA). If you
have 40 quarters or SSA coverage, you are exempt from
the requirement to file Form I-864. You can acquire 40
qualifying quarters in the following ways:
Working in the United States for 40 quarters in which
you received the minimum income established by the
Social Security Administration; or
By being credited under section 213(a)(3)(B) of the
Immigration and Nationality Act with quarters worked
by your spouse during the marriage or a parent during
the time you were under 18 years of age; or
A combination of the above.

(2) Intending immigrant is a child who will become a U.S.
citizen immediately upon entry under the Child
Citizenship Act of 2000 (CCA). Under the CCA, some
children become U.S. citizens immediately upon admission
to the United States or adjustment of status to that of a
lawful permanent resident. For this classification to apply:
At least one parent of the child is a U.S. citizen;
The child is under 18 years of age at the time of
admission or adjustment of status;
The child is residing permanently in the United States in
the legal and physical custody of the U.S. parent; and
If the child is an alien orphan child adopted abroad, the
adoption was legally finalized prior to admission to the
United States and both adoptive parents or the unmarried
U.S. citizen parent personally observed the alien orphan
before or during the adoption proceeding.
If the citizen parent(s) adopted the alien orphan abroad,
but at least one of the adoptive parents or the unmarried
parent did not see and observe the alien orphan before or
during the foreign adoption proceeding, then an affidavit
of support under this part is still required unless the
citizen parent submits evidence that, under the law of the
state of the alien orphan's intended residence in the
United States, the foreign adoption decree is entitled to
recognition without the need for a formal administrative
or judicial proceeding in the State of proposed residence.
Orphans whose adoptions are not legally finalized until
after admission to the United States will not qualify for
this exemption and must file a Form I-864.
(3) You are filing for an immigrant visa as a selfpetitioning widow(er). If you are filing as a selfpetitioning widow(er) using Form I-360, you are exempt
from the Affidavit of Support requirements if your Form
I-360 is approved and you are applying for lawful
permanent residence.
(4) You are filing for an immigrant visa as a self-petitioning
battered spouse or child. If you are filing as a selfpetitioning battered spouse or child using
Form I-360, you are exempt from the Affidavit of Support
requirements if your Form I-360 is approved and you are
applying for lawful permanent residence.
Form I-864W (01/15/06)N

Other Information.
Penalties.
The Government may pursue verification of any information
provided on or in support of this form. If you include in this
affidavit of support any information that you know to be false,
you may be liable for criminal prosecution under the laws of
the United States.

Privacy Act Notice.
Authority for the collection of the information requested on
this form is contained in 8 U.S.C. 1182a(4), 1183a, 1184(a),
and 1258. The information will be used principally by an
immigration judge, USCIS, or a Consular Officer to whom it
is furnished, to determine an alien's eligibility for benefits
under the Immigration and Nationality Act, specifically
whether he or she has adequate means of financial support and
will not become a public charge. Submission of the
information is voluntary. Failure to provide the information
will result in denial of the application for an immigrant visa or
adjustment of status.

Reporting Burden.
A person is not required to respond to a collection of
information unless it displays a currently valid OMB control
number. We try to create forms and instructions that are
accurate, can be easily understood, and which impose the least
burden on you to provide us with information. Often this is
difficult because some immigration laws are very complex.
The estimated average time to complete and file this form is
as follows: (1) 15 minutes to learn about the law and form;
(2) 15 minutes to complete the form; and (3) 30 minutes to
assemble and file the form; for a total estimated average of 1
hour per form.
If you have comments regarding the accuracy of this estimate
or suggestions for making this form simpler, write to U.S.
Citizenship and Immigration Services, Regulatory
Management Division, Attn: OMB No. 1615-0075, 111
Massachusetts Avenue N.W., Washington, D.C. 20529. Do
not mail your completed form to this address

The information may also, as a matter of routine use, be
disclosed to other Federal, State and local agencies providing
means-tested public benefits for use in civil action against the
sponsor for breach of contract. Social Security numbers may
be verified with the Social Security Administration consistent
with the consent signed as part of the contract in Part 3 of the
Form I-864. They may also be disclosed as a matter of routine
use to other Federal, State, local, and foreign law enforcement
and regulatory agencies to enable these entities to carry out
their law enforcement responsibilities.

USCIS Forms and Information.
To order USCIS forms, call our toll-free forms line at
1-800-870-3676. You can also obtain forms and information
on immigration laws, regulations and procedures by
telephoning our National Customer Service Center at
1-800-375-5283 or visiting our internet website at
www.uscis.gov.

Use InfoPass for Appointments.
As an alternative to waiting in line for assistance at your local
USCIS office, you can now schedule an appointment through
our internet-based system, InfoPass. To access the system,
visit our website at www.uscis.gov. Use the InfoPass
appointment scheduler and follow the screen prompts to set up
your appointment. InfoPass generates an electronic
appointment notice that appears on the screen. Print the notice
and take it with you to your appointment. The notice gives the
time and date of your appointment, along with the address of
the USCIS office.

Form I-864W Instructions (Rev. 01/15/06)N Page 2

OMB No. 1615-0075; Expires 10/31/07

I-864W, Intending Immigrant's
Affidavit of Support Exemption

Department of Homeland Security
U.S. Citizenship and Immigration Services

Part 1. Information about the intending immigrant. (You or your adopted child.)
For Government
Use Only

Last Name

1. Name

First Name

Middle Name

Street Number and Name (include apartment number)

2. Address

City

State or Province

Country

Zip/Postal Code

3. Date of Birth

(mm/dd/yyyy)

4. Country of Birth
(city/country)
5. Telephone Number

(Include area code or country and city codes)

This I-864W:
does not meet the
requirements of
exemption.

meets the
requirements of
exemption.

Reviewer

6. Social Security
Number (if any)
7. Alien Registration
Number (if any)

Location

Date (mm/dd/yyyy)

Part 2. Reason for exemption.
I am EXEMPT from filing a Form I-864 Affidavit of Support because:
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, 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.
I am filing for an immigrant visa or adjustment of status as a self-petitioning widow(er)
using Form I-360.
I am filing for an immigrant visa or adjustment of status as a battered spouse or child using
Form I-360.

Part 3. Concluding provision.
I,
of perjury under the laws of the United States that:

, certify under penalty

(a) I know the contents of this exemption request which I signed;
(b) All the statements in this exemption request are true and correct; and
(c) I authorize the Social Security Administration to release information about me in its
records to the Department of State and U.S. Citizenship and Immigration Services.

(Signature of intending immigrant, or of U.S. citizen parent
if intending immigrant is less than 14 years old)

(Date--mm/dd/yyyy)
Form I-864W (Rev. 01/15/06)N