Form I-864EZ Affidavit of Support Under Section 213A of the Act

OMB No. 1615-0075; Expires 10/31/2011

I-864EZ, Affidavit of Support
Under Section 213A of the Act

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.

2. You filed or are filing a Form I-140, Immigrant Petition
for Alien Worker, for the immigrant you are sponsoring;

Use black ink.

3. You are a joint sponsor;

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

4. You are a "substitute sponsor" filing because the original
I-130 petitioner is deceased.

What Is the Purpose of This Form?
Form I-864EZ is a shorter version of Form I-864 designed for
cases that meet certain criteria. Form I-864 or Form I-864EZ
is legally required for many family-based immigrants to show
that the intending immigrant has adequate means of financial
support and is unlikely to become a public charge. For more
information about Form I-864EZ, 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.

Who May Use Form I-864EZ?
You may use Form I-864EZ IF ALL the following conditions
apply:
1. You are the person who filed or is filing the Form I-130,
Petition for Alien Relative, for a relative being sponsored;
2. The relative you are sponsoring is the only person listed on
the Form I-130 petition;

How Is This Form Used?
This form is a contract between a sponsor and the U.S.
Government. The person completing and signing this form is
the sponsor. By signing Form I-864EZ, you are agreeing to
use your income and resources to support the intending
immigrant named in this form, if it becomes necessary. You
must show on this form that you have enough income to
ensure that the sponsored immigrant will not have to rely on
means-tested public benefits for support in the United States.
In most cases, the submission of this form will make the
sponsored immigrant ineligible for Federal, State, or local
means-tested public benefits, because an agency that provides
means-tested public benefits will consider your income and
resources as available to the sponsored immigrant in
determining eligibility for the program.
If the immigrant sponsored in this affidavit does receive a
Federal, State, or local means-tested public benefit, the agency
providing the benefit may require you to repay the cost of
those benefits. That agency can sue you if you do not repay
the cost of the benefits provided.

Who Is Required to File a Form I-864W
Instead of a Form I-864 or I-864EZ?
The following types of intending immigrants must properly
complete and submit Form I-864W, Intending Immigrant's
Affidavit of Support Exemption, instead of a Form I-864 or
Form I-864EZ:

3. The income you are using to qualify is based entirely on
your salary or pension and is shown on one or more Forms
W-2 provided by your employer(s) or former employer(s).

An intending immigrant who has or can be credited with 40
quarters of work. The Social Security Administration
(SSA) can provide information on how to count and provide
evidence of quarters of work.

Who May Not Use Form I-864EZ?
You must complete Form I-864 (and not Form I-864EZ) if
any of the following conditions apply:

An intending immigrant who will, upon admission, acquire
U.S. citizenship under section 320 of the Immigration and
Nationality Act, as amended by the Child Citizehship Act of
2000 (CCA); and

1. The relative you are sponsoring is not the only person
immigrating based upon the underlying visa petition;

A self-petitioning widow(er) or qualifying battered spouse
or child.
Form I-864EZ Instructions (Rev. 10/08/10)Y

Who Completes This Form?
Only the U.S. citizen or lawful permanent resident who filed a
Form I-130 relative visa petition for a family member, may
complete this form. A sponsor is required to be 18 years old
and domiciled in the United States, its territories or
possessions (see Step-by-Step Instructions for more
information on domicile).

What Are the Income Requirements?

To qualify as a sponsor, you must demonstrate that you have
an income of at least 125 percent of the current Federal
poverty guideline for your household size. The Federal
poverty line, for purposes of this form, is updated annually
and can be found on Form I-864P, Poverty Guidelines.
If you are on active duty in the U.S. Armed Forces, including
the Army, Navy, Air Force, Marines, or Coast Guard, and you
are sponsoring your spouse or minor child, you only need to
have an income of 100 percent of the Federal poverty line for
your household size.

How Do I Count Household Size?
Your household size includes yourself and the following
individuals, no matter where they live: any spouse, any
dependent children under the age of 21, any other dependents
listed on your most recent Federal income tax return, the
person being sponsored in this affidavit of support, and any
immigrants previously sponsored with a Form I-864 or Form
I-864EZ affidavit of support whom you are still obligated to
support.

How Long Does My Obligation
as a Sponsor Continue?
Your obligation to support the immigrant you are sponsoring
in this affidavit of support will continue until the sponsored
immigrant becomes a U.S. citizen, or can be credited with 40
qualifying quarters of work in the United States. Although 40
qualifying quarters of work (credits) generally equates to 10
years of work, in certain cases the work of a spouse or parent
adds qualifying quarters toward eligibility. The Social
Security Administration can provide information on how to
count qualifying quarters (credits) of work. The obligation
also ends if you or the sponsored immigrant dies or if the
sponsored immigrant ceases to be a lawful permanent resident
and departs the United States. Divorce does not end the
sponsorship obligation.

Do not complete Form I-865 at the same time that you
complete the I-864EZ. You should complete and submit
Form I-865 to USCIS only when the address you indicated on
the original Form I-864EZ has changed. A sponsor who fails
to submit a Form I-865 within 30 days of a change of address
may be fined.
Please see Form I-865 for further directions on filing the
Sponsor's Change of Address. This requirement does not
relieve a sponsor who is a lawful permanent resident from
submitting Form AR-11 within ten days of a change of
address.

When Do I Complete Form I-864EZ
and Where Do I Send It?
If the intending immigrant will apply for an immigrant
visa at a U.S. Embassy or Consulate overseas:
Complete Form I-864EZ when it is mailed to you from the
National Visa Center (NVC). Different instructions apply to
some cases so follow the instructions provided by the National
Visa Center for your particular case. The instructions on
when and where to submit Form I-864EZ are included in the
information packet that is mailed to you with Form I-864EZ.
The form must be submitted to the government within 1 year
of your signature date on the form.
If the intending immigrant will adjust status in the United
States:
Complete Form I-864EZ when the intending immigrant is
ready to submit his or her Application to Register Permanent
Residence or Adjust Status, Form I-485. Then, give the
completed Form I-864EZ and all supporting documentation to
the intending immigrant to submit with his or her application
for adjustment of status. This form and all accompanying
documents must be submitted within one year of the time you
complete and sign this form.
For privacy, you may enclose these documents in a sealed
envelope marked "Form I-864EZ: To be opened only by a
U.S. government official." You may be requested to submit
updated information if there is a significant delay in
processing.

Do I Have to Report My
Change of Address If I Move?
Federal law requires that a sponsor report every change of
address to the USCIS within 30 days of the change. To do
this, send a completed Form I-865, Sponsor's Change of
Address, to the Service Center having jurisdiction over your
new address.
Form I-864EZ Instructions (Rev. 10/08/10)Y Page 2

Step-By-Step Instructions

Form I-864EZ is divided into seven parts. The information below will help you fill out the form.
Part 1. Qualifying to Use Form I-864EZ.
You may use Form I-864EZ if the statements in 1(a), 1(b) and
1(c) are all true. If you cannot check "Yes" to all three boxes,
you do NOT qualify to use Form I-864 EZ and therefore must
use Form I-864. Submission of the incorrect form will delay
processing.
a. Check "Yes" if you are the petitioner who is filing or who
has already filed Form I-130, Petition for Alien Relative;
Form I-129F, Petition for Alien Fiance(e); Form I-600,
Petition to Classify Orphan as an Immediate Relative; or
Form I-600A, Application for Advance Processing of
Orphan Petition.
b. Check "Yes" if you are using only your own earned or
retirement income that can be documented with an IRS
Form W-2. If you are self-employed, you must check
"No" to the question and you cannot use Form I-864EZ.
c. The term "immigrating with" in this statement means "on
the same visa petition". Thus, if the person you are
sponsoring is an immediate relative (spouse, child, or
certain parents of U.S. citizens), you can automatically
check "Yes" for this box because every immediate relative
has his or her own visa petition. If the person you are
sponsoring is a family-based preference immigrant, and
the family members listed on the same visa petition are
immigrating with or within 6 months of the sponsored
immigrant, you must check "No" for this box and you
cannot use Form I-864EZ.

Part 2. Information on Immigrants
You Are Sponsoring.
6. Alien Registration Number. An "A-number" is an Alien
Registration Number assigned by the former Immigration and
Naturalization Service (INS) or U.S. Citizenship and
Immigration Services (USCIS). If the intending immigrants
you are sponsoring have not previously been in the United
States or have only been in the United States as tourists, they
probably do not have A-numbers. Persons with A-numbers
can locate the number on their INS or USCIS-issued
documentation.

Part 3. Information on the Sponsor.
10. Country of Domicile. This question is asking you to
indicate the country where you maintain your principal
residence and where you plan to reside for the foreseeable

future. If your mailing address and/or place of residence is
not in the United States, but your country of domicile is the
United States, you must attach a written explanation and
documentary evidence indicating how you meet the domicile
requirement. If you are not currently living in the United
States, you may meet the domicile requirement if you can
submit evidence to establish that any of the following
conditions apply:
A. You are employed by a certain organization.
Some individuals employed overseas are automatically
considered to be domiciled in the United States because of the
nature of their employment. The qualifying types of
employment include employment by:
The U.S. government;
An American institution of research recognized by the
Secretary of Homeland Security (The list of qualifying
institutions may be found at 8 CFR 316.20);
A U.S. firm or corporation engaged in whole or in part in
the development of foreign trade and commerce with the
United States, or a subsidiary of such a firm or corporation;
A public international organization in which the United
States participates by treaty or statute;
A religious denomination having a bona fide organization in
the United States, if the employment abroad involves the
person's performance of priestly or ministerial functions on
behalf of the denomination; or
A religious denomination or interdenominational
missionary organization having a bona fide organization in
the United States, if the person is engaged solely as a
missionary.
B. You are living abroad temporarily. If you are not
currently living in the United States, you must show that your
trip abroad is temporary and that you have maintained your
domicile in the United States. You can show this by
providing proof of your voting record in the United States,
proof of paying U.S. State or local taxes, proof of having
property in the United States, proof of maintaining bank or
investment accounts in the United States, or proof of having a
permanent mailing address in the United States. Other proof
could be evidence that you are a student studying abroad or
that a foreign government has authorized a temporary stay.

Form I-864EZ Instructions (Rev. 10/08/10) Page 3

C. You intend in good faith to reestablish your domicile in
the United States no later than the date of the intending
immigrant's admission or adjustment of status. You must
submit proof that you have taken concrete steps to establish
you will be domiciled in the United States at a time no later
than the date of the intending immigrant's admission or
adjustment of status. Concrete steps might include accepting a
job in the United States, signing a lease or purchasing a
residence in the United States, or registering children in U.S.
schools. Please attach proof of the steps you have taken to
establish domicile as previously described.

credited work in the United States, or obtaining a new grant of
adjustment of status while in removal proceedings based on a
new affidavit of support, if one is required.

15. Military Service.

Part 5. Sponsor's Income and Employment.

Check "yes" if you are the petitioning sponsor and on active
duty in the U.S. Army, Navy, Air Force, Marines, or Coast
Guard, other than for training. If you provide evidence that
you are currently on active duty in the military and you are
petitioning for your spouse or minor child, you will need to
demonstrate income at only 100 percent of the poverty level
for your household size, instead of at 125 percent of the
poverty level. (See Form I-864P for information on the
poverty levels.) Check "no" if you are not on active duty in
the U.S. military.

18. Current Individual Annual Income.

Part 4. Sponsor's Household Size.
This section asks you to add together the number of persons
for whom you are financially responsible. Some of these
persons may not be residing with you. Make sure you do not
count any individual more than once, since in some cases the
same person could fit into two categories.
16(a) - This line is already completed for you.
16(b) - If you are married, and your spouse was not included
in line (a), enter "1" here.
16(c) - Enter the number of unmarried children you have who
are under age 21, even if you do not have legal custody of
these children. You may exclude any unmarried children
under 21, if these children have reached majority under the
law of their place of domicile and you do not claim them as
dependents on your income tax returns.
16(d) - Enter the number of lawful permanent residents whom
you are currently obligated to support based on your previous
submission of Form I-864 or Form I-864EZ as a petitioning,
substitute, or joint sponsor. Include only those persons who
have already immigrated to the United States. Do not include
anyone for whom your obligation to support has ended
through the sponsored immigrant's acquisition of U.S.
citizenship, death, abandonment of lawful permanent residence
in the United States, aquisition of 40 quarters of earned or

16(e) - Enter the number of any other dependents. You must
include each and every person whom you have claimed as a
dependent on your most recent Federal income tax return,
even if that person is not related to you. Even if you are not
legally obligated to support that person, you must include the
person if in fact you did support that person and claimed the
person as a dependent.

Enter your current individual earned or retirement annual
income that you are using to meet the requirements of this
form and indicate the total on this line.
You may include evidence supporting your claim about your
expected income for the current year if you believe that
submitting this evidence will help you establish ability to
maintain sufficient income. You are not required to submit
this evidence, however, unless specifically instructed to do
so by a Government official. For example, you may include
a recent letter from your employer, showing your employer's
address and telephone number, and indicating your annual
salary. You may also provide pay stub(s) showing your
income for the previous six months. If your claimed income
includes alimony, child support, dividend or interest income,
or income from any other source, you may also include
evidence of that income.

19. Federal Income Tax Information.
You must provide either an IRS transcript or a photocopy
from your own records of your Federal individual income tax
return for the most recent tax year. If you believe additional
returns may help you to establish your ability to maintain
sufficient income, you may submit transcripts or photocopies
of your Federal individual income tax returns for the 3 most
recent years.
You are not required to have the IRS certify the transcript or
photocopy unless specifically instructed to do so by a
Government official; a plain transcript or photocopy is
acceptable. Telefile tax records are not acceptable proof of
filing.
Do not submit copies of your State income tax returns. Do
not submit any tax returns that you filed with any foreign
government unless you claim that you were not required to
file a Federal tax return with the United States government
and you wish to rely on the foreign return solely to establish
the amount of your income that is not subject to tax in the
United States.

Form I-864EZ Instructions (Rev. 10/08/10)Y Page 4

If you provide a photocopy of your tax return(s), you must
include a copy of each and every FormW-2 and Form 1099
that relates to your return(s). Do not include copies of these
Forms if you provide an IRS transcript of your return(s) rather
than a photocopy.
If you were required to file a Federal income tax return during
any of the previous 3 tax years but did not do so, you must file
any and all late returns with the IRS and attach an IRSgenerated tax return transcript documenting your late filing
before submitting the I-864EZ Affidavit of Support. If you
were not required to file a Federal income tax return under
U.S. tax law for any other reason, attach a written explanation
including evidence of the exemption and how you are subject
to it. Residence outside of the United States does not exempt
U.S. citizens or lawful permanent residents from filing a U.S.
Federal income tax return. See "Filing Requirements" in the
IRS Form 1040 Filing Instructions to determine whether you
were required to file.
For purposes of this affidavit, the line for gross (total) income
on IRS Forms 1040 and 1040A will be considered when
determining income. For persons filing IRS Form 1040EZ,
the line for adjusted gross income will be considered.
Obtaining Tax Transcripts. You may use Internal Revenue
Service (IRS) Form 4506-T to request tax transcripts from the
IRS. Complete IRS Form 4506-T with the ending date for
each of your three most recent tax years listed on line 9.
Follow all instructions for completing and filing Form 4506-T
with the IRS.

Part 6. Sponsor's Contract.
Read the contract carefully, print your name, and then sign
and date the form. If you do not print your name and sign
and date the form in lines 20 and 21, the immigrant you
are sponsoring cannot be issued a visa or be granted
adjustment of status.

Other Information.
Penalties
The Government may pursue verification of any information
provided on or in support of this form, including employment,
income, financial or other institutions, the Internal Revenue
Service, or the Social Security Administration. 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.
If you fail to give notice of your change of address, as
required by 8 U.S.C. 1183a(d) and 8 CFR 213a.3, you may be
liable for the civil penalty established by 8 U.S.C. 1183a(d)
(2). The amount of the civil penalty will depend on whether
you failed to give this notice because you were aware that
thesponsored immigrant received Federal, State, or local
means-tested public benefits.

If the failure to report your change of address occurs with
knowledge that the sponsored immigrant received meanstested public benefits (other than benefits described in section
401(b), 403(c)(2), or 4ll(b) of the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, which are
summarized in the contract in Part(6) such failure may result
in a fine of not less than $2,000 or more than $5,000.
Otherwise, the failure to report your change of address may
result in a fine not less than $250 or more than $2,000.

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.
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 6 of the
Form I-864EZ. 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-864EZ Instructions (Rev. 10/08/10)Y Page 5

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) 30 minutes to learn about the law and form; (2)
40 minutes to complete the form; and (3) 80 minutes to
assemble and file the form; for a total estimated average of 2
hours and 30 minutes per form.
If you have comments regarding the accuracy of this estimate,
or suggestions for making this form simpler, you can write to
the U.S. Citizenship and Immigration Services, Regulatory
Products Division, Office of the Executive Secretariat, 20
Massachusetts Ave., N.W., Washington, DC 20259-2210
OMB No. 1615-0075. Do not mail your completed
Affidavit of Support to this address.

Check List
The following items must be submitted with Form
I-864EZ:
For ALL sponsors:
A copy of your individual Federal income tax return,
including W-2s for the most recent tax year, or a statement
and/or evidence describing why you were not required to file.
Also include a copy of each and every Form 1099, Schedule,
and any other evidence of reported income. You may submit
this information for the most recent three tax years, pay stub(s)
from the most recent six months, and/or a letter from your
employer if you believe any of these items will help you
qualify.
For SOME sponsors:
If you are on active duty in the U.S. Armed Forces and are
sponsoring your spouse or child using the 100 percent of
poverty level, proof of your active military status.

Form I-864EZ Instructions (Rev. 10/08/10)Y Page 6

OMB No. 1615-0075; Expires 10/31/2011

I-864EZ, Affidavit of Support
Under Section 213A of the Act

Department of Homeland Security

U.S. Citizenship and Immigration Services

Part 1. Qualifying to use Form I-864EZ.
The answer must be "Yes" to all of the following statements to qualify to use Form I-864EZ.

For Government
Use Only

a. I am the petitioner of the family member sponsored on this form.

No (Use I-864).

This I-864EZ:

No (Use I-864).

does not meet the
requirements of
section 213A.

b. I am using only my own earned or retirement income, which is
documented using IRS Form W-2.

c. The sponsored immigrant is the only person immigrating based
on the underlying visa petition.

Yes

Yes

Yes

No (Use I-864).

Reviewer

Part 2. Information on the immigrant you are sponsoring.
1. Name of Immigrant

meets the
requirements of
section 213A.

Last Name

Location

First Name

Middle Name
Date (mm/dd/yyyy)

2. Mailing Address

3. Telephone Number
4. Date of Birth
(mm/dd/yyyy)
5. Social Security
Number (if any)
6. Alien Registration
Number (if any)

Street Number and Name (include apartment number)
City

State or Province

Country

Zip/Postal Code

(Include area code or country and city codes)

A-

Part 3. Information on the Sponsor (You).
7. Name of Sponsor

Last Name
First Name

8. Mailing Address

Middle Name

Street Number and Name (include apartment number)
City

State or Province

Country

Zip/Postal Code
Form I-864EZ (Rev. 10/08/10)Y

Part 3. Information on the Sponsor (You).

(Continued.)
For Government
Use Only

Street Number and Name (include apartment number)

9. Place of Residence
(if different from
mailing address)

City

State or Province

Country

Zip/Postal Code

10. Country of Domicile Country
11. Date of Birth
(mm/dd/yyyy)
12. Place of Birth

State or Province

City

Country

13.U.S. Social Security
Number (required)
14.Citizenship/Residency
I am a U.S. citizen
I am a Lawful Permanent Resident. My alien registration number is A -

15.Military Service
I am currently on active duty in the U.S. armed services.
Yes

No

Part 4. Sponsor's household size.
16. Your Household Size - Do not count anyone twice.
a. Yourself and the person you are sponsoring on this form.

2

b. Your spouse.
c. Your dependent children under age 21.
d. If you have sponsored any other persons on an I-864 who are
now lawful permanent residents in the United States, enter the
number here.
e. If you have any other dependents listed on you most recent
Federal Income tax return, enter the number here.

f. Add together lines a, b, c, d and e and enter the number here.
This is your HOUSEHOLD SIZE for the purposes of this form.
Form I-864EZ (Rev. 10/08/10)Y Page 2

Part 5. Sponsor's income and employment.
17. I am currently:
a.

b.

Employed as a/an

.

Name of Employer (if applicable)

.

Name of Second Employer (if applicable)

.

Retired since (mm/dd/yyyy)

.

Name of Former Employer

.

For Government
Use Only

$

18. My individual annual income is currently:

19. Federal income tax information.
I have filed a Federal tax return for each of the three most recent tax years. I have attached the
required photocopy or transcript of my Federal tax return for only the most recent tax year.
My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal tax
returns for the most recent three years was:

Tax Year

Total Income
(most recent)

$

(2nd most recent) $
(3rd most recent)

$

(Optional) I have attached photocopies or transcripts of my Federal tax returns for my second
and third most recent tax years.

Part 6. Sponsor's Contract.
Please note that, by signing this Form I-864EZ, you agree to assume certain specific obligations under the Immigration
and Nationality Act and other Federal laws. The following paragraphs describe those obligations. Please read the
following information carefully before you sign the 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 My Signing a Form I-864EZ?

If you sign a Form I-864EZ on behalf of any person (called the "intending immigrant") who is applying for an immigrant
visa or for adjustment of status to a permanent resident, and that intending immigrant submits the Form I-864EZ to the
U.S. Government with his or her application for an immigrant visa or adjustment of status, under section 213A of the
Immigration and Nationality Act these actions create a contract between you and the U. S. Government. The intending
immigrant's becoming a 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 an alien likely to become a public charge, the U.S. Government can consider your
income and assets to be available for the support of the intending immigrant.

Form I-864EZ (Rev. 10/08/10)Y Page 3

Part 6. Sponsor's Contract. (Continued.)
What If I Choose Not to Sign a Form I-864EZ?

You cannot be made to sign a Form I-864EZ if you do not want to do so. But if you do not sign the Form I-864EZ, the
intending immigrant may not be able to become a permanent resident in the United States.
What Does Signing the Form I-864EZ Require Me to Do?

If an intending immigrant becomes a permanent resident in the United States based on a Form I-864EZ that you have
signed, then, until your obligations under the Form I-864EZ terminate, you must:
-- 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 and the person is your husband, wife, unmarried child under 21 years old.)
-- Notify 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 permanent resident in the United States based on a Form I-864EZ that you have
signed, then until your obligations under the Form I-864EZ terminate, your income and assets may be considered
("deemed") to be 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, but not
limited to, 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 permanent resident based on the Form I-864EZ that
you signed, that person may sue you for this support.
If a Federal, State or local agency, or a private agency provides any covered means-tested public benefit to the person who
becomes a 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 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-864EZ will end if the person who becomes a permanent resident based on a Form
I-864EZ that you signed:
Becomes a U.S. citizen;
Has worked, or can be credited with, 40 quarters of coverage under the Social Security Act;
No longer has lawful permanent resident status, and has departed the United States;

Form I-864EZ (Rev. 10/08/10)Y Page 4

Part 6. Sponsor's Contract.

(Continued.)

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
Dies.
Note that divorce does not terminate your obligations under this Form I-864EZ.
Your obligations under a 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.

20. I,

,

(Print Sponsor's Name)

certify under penalty of perjury under the laws of the United States that:

a. I know the contents of this affidavit of support that I signed.
b. All the factual statements in this affidavit of support are true and correct.
c. 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 permanent resident of the United States;

d. 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;

e. 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 U.S. Internal Revenue Service; and

f.

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.

g. Any other evidence submitted is true and correct.
21.

(Sponsor's Signature)

(Date--mm/dd/yyyy)

Part 7. Information on Preparer, if prepared by someone other than the sponsor.
I certify under penalty of perjury under the laws of the United States that I prepared this affidavit of support at
the sponsor's request and that this affidavit of support is based on all information of which I have knowledge.
Signature:
Printed Name:

Date:
(mm/dd/yyyy)

Firm Name:
Address:
Telephone Number:

E-Mail Address:

Business State ID # (if any)

Form I-864EZ (Rev. 10/08/10)Y Page 5