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

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

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

Department of Homeland Security

U.S. Citizenship and Immigration Services

Part 1. Basis for filing Affidavit of Support.
1. I,
am the sponsor submitting this affidavit of support because (Check only one box):

For Government
Use Only

,

This I-864 is from:

a.

I am the petitioner. I filed or am filing for the immigration of my relative.

b.

I filed an alien worker petition on behalf of the intending immigrant, who is related to me as
my

c.

I have an ownership interest of at least 5 percent in
,
which filed an alien worker petition on behalf of the intending immigrant, who is related to
me as my

d.

I am the only joint sponsor.

e.

I am the

f.

The original petitioner is deceased. I am the substitute sponsor. I am the intending
immigrant's

first

the Petitioner
a Joint Sponsor #
______________
the Substitute
Sponsor
5% Owner

second of two joint sponsors. (Check appropriate box.)

This I-864:
does not meet the
requirements of
section 213A.

.

Part 2. Information on the principal immigrant.

meets the
requirements of
section 213A.

2. Last Name
First Name

Middle Name

Reviewer

3. Mailing Address Street Number and Name (Include Apartment Number)
City

State/Province

4. Country of Citizenship

Location

Zip/Postal Code Country

Date (mm/dd/yyyy)

Number of Affidavits of
Support in file:

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

6. Alien Registration Number (if any)

7. U.S. Social Security Number (if any)

1

2

A-

Part 3. Information on the immigrant(s) you are sponsoring.
8.

I am sponsoring the principal immigrant named in Part 2 above.
Yes

9.

No (Applicable only in cases with two joint sponsors)

I am sponsoring the following family members immigrating at the same time or within six months of the principal
immigrant named in Part 2 above. Do not include any relative listed on a separate visa petition.
Name

Relationship to
Sponsored Immigrant

Date of Birth
(mm/dd/yyyy)

U.S.Social Security
Number (if any)

A-Number (if any)

a.
b.
c.
d.
e.

10. Enter the total number of immigrants you are sponsoring on this form from Part 3, Items 8 and 9.
Form I-864 (Rev. 10/08/10)Y

Part 4. Information on the Sponsor.
11. Name

Last Name

For Government
Use Only

First Name

12. Mailing Address

Middle Name

Street Number and Name (Include Apartment Number)

City

State or Province

Country

Zip/Postal Code

13. Place of Residence Street Number and Name (Include Apartment Number)
(if different from
mailing address)

City

State or Province

Country

Zip/Postal Code

14. Telephone Number (Include Area Code or Country and City Codes)
15. Country of Domicile
16. Date of Birth (mm/dd/yyyy)
17. Place of Birth (City)

State or Province

Country

18. U.S. Social Security Number (Required)
19. Citizenship/Residency
I am a U.S. citizen.
I am a U.S. national (for joint sponsors only).
I am a lawful permanent resident. My alien registration number is AIf you checked box (b), (c), (d), (e) or (f) in line 1 on Page 1, you must include proof of your
citizen, national, or permanent resident status.
20. Military Service (To be completed by petitioner sponsors only.)
I am currently on active duty in the U.S. armed services.

Yes

No

Form I-864 (Rev. 10/08/10)Y Page 2

Part 5. Sponsor's household size.
For Government
Use Only

21. Your Household Size - DO NOT COUNT ANYONE TWICE

Persons you are sponsoring in this affidavit:
a. Enter the number you entered on line 10.

Persons NOT sponsored in this affidavit:

1

b. Yourself.
c. If you are currently married, enter "1" for your spouse.
d. If you have dependent children, enter the number here.
e. If you have any other dependents, enter the number here.
f. If you have sponsored any other persons on an I-864 or I-864 EZ
who are now lawful permanent residents, enter the number here.
g. 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.
h. Add together lines and enter the number here. Household Size:

Part 6. Sponsor's income and employment.
22. I am currently:
a.

Employed as a/an

.

Name of Employer #1 (if applicable)

.

Name of Employer #2 (if applicable)

.

b.

Self-employed as a/an

.

c.

Retired from
(Company Name)

d.

.

since
(Date)

.

Unemployed since

23. My current individual annual income is:

(Date)

$
(See Step-by-Step Instructions)

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

24. My current annual household income:

For Government
Use Only

$

a. List your income from line 23 of this form.

Household Size =

b. Income you are using from any other person who was counted in your household
size, including, in certain conditions, the intending immigrant. (See step-by-step
instructions.) Please indicate name, relationship and income.
Name

Relationship

Current Income

Poverty line for year

$

_______________ is:

$
$

$
$

c. Total Household Income:

$

(Total all lines from 24a and 24b. Will be Compared to Poverty Guidelines -- See Form I-864P.)

d.

The persons listed above have completed Form I-864A. I am filing along with this
form all necessary Forms I-864A completed by these persons.

e.

The person listed above,

does not need to
(Name)

complete Form I-864A because he/she is the intending immigrant and has no
accompanying dependents.

25. Federal income tax return 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.

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

Part 7. Use of assets to supplement income. (Optional)
If your income, or the total income for you and your household, from line 24c exceeds the
Federal Poverty Guidelines for your household size, YOU ARE NOT REQUIRED to
complete this Part. Skip to Part 8.

For Government Use
Only

Household Size =

26. Your assets (Optional)
a. Enter the balance of all savings and checking accounts.
b. Enter the net cash value of real-estate holdings. (Net means
current assessed value minus mortgage debt.)
c. Enter the net cash value of all stocks, bonds, certificates of
deposit, and any other assets not already included in lines 26
(a) or (b).
d. Add together lines 26 a, b and c and enter the
number here.

$

Poverty line for year
_______________ is:

$

$

$

TOTAL: $

27. Your household member's assets from Form I-864A. (Optional)
Assets from Form I-864A, line 12d for
$
(Name of Relative)

28. Assets of the principal sponsored immigrant. (Optional)
The principal sponsored immigrant is the person listed in line 2.
a. Enter the balance of the sponsored immigrant's savings and
checking accounts.

$

b. Enter the net cash value of all the sponsored immigrant's real
estate holdings. (Net means investment value minus
mortgage debt.)

$

c. Enter the current cash value of the sponsored immigrant's
stocks, bonds, certificates of deposit, and other assets not
included on line a or b.
d. Add together lines 28a, b, and c, and enter the number
here.

$
$

29. Total value of assets.
Add together lines 26d, 27 and 28d and enter the
number here.

TOTAL:

$

The total value of all
assests, line 29, must equal
5 times (3 times for
spouses and children of
USCs, 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 24c.

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

Part 8. 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 and other Federal laws. The following paragraphs describe those obligations. Please read the following
information carefully before you sign the 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 a Form I-864?

If you sign a 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 permanent resident, and that intending immigrant submits the Form I-864 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.
What If I choose Not to Sign a Form I-864?

You cannot be made to sign a Form 1-864 if you do not want to do so. But if you do not sign the Form I-864, the
intending immigrant may not be able to become a permanent resident in the United States.
What Does Signing the Form I-864 Require Me to do?

If an intending immigrant becomes a permanent resident in the United States based on a Form I-864 that you have signed,
then, until your obligations under the Form I-864 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-864 that you have signed,
then until your obligations under the Form I-864 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.

Contract continued on following page.
Form I-864 (Rev. 10/08/10)Y Page 6

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-864 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-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 will end if the person who becomes a permanent resident based on a Form I-864 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;
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-864.
Your obligations under a Form I-864 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.

30. 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 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 permanent residents 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
Sign on following page.
Form I-864 (Rev. 10/08/10)Y Page 7

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 and all other evidence submitted is true and correct.
31.

(Sponsor's Signature)

(Date-- mm/dd/yyyy)

Part 9. 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-864 (Rev. 10/08/10)Y Page 8