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

Affidavit of Support Under Section 213A of the Act
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0075
Expires 09/30/2012

Section 213A Review
MEETS
requirements
Reviewed By:
Office:
Date: M M / D D

► START HERE - Type or print in black ink.

Part 1. Basis For Filing Affidavit of Support

Number of Support Affidavits in File

DOES NOT MEET
requirements

DRAFT - Not For Production

For
USCIS
Use
Only

Affidavit of Support Submitter
Petitioner
1st Joint Sponsor
2nd Joint Sponsor
Substitute Sponsor
5% Owner

USCIS
Form I-864

1

2

Remarks

/

YYYY

Mailing Address

2.a. Street Number
and Name

1.
am the sponsor submitting this affidavit of support because
(Check only one box):
1.a.

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

1.b.

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

2.b. Apt.

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

1.d.

I am the only joint sponsor.

1.e.

I am the

1.f.

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

first

2.d. State

2.e. Zip Code

Postal Code

2.g. Province

2.h. Country

Other Information

3.

Country of Citizenship

4.

Date of Birth

5.

Alien Registration Number (A-Number)

second of two joint sponsors.

NOTE: If you check box 1.b., 1.c., 1.d., 1.e., or 1.f., you must
include proof of your citizen, national, or lawful permanent
resident status.

Part 2. Information on the Principal Immigrant
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Flr.

2.c. City or Town

2.f.

1.c.

Ste.

(mm/dd/yyyy) ►

► A-

1.c. Middle Name

Form I-864 03/08/12 N

Page 1 of 9

Part 3. Information on the Immigrant(s) You Are Sponsoring
1.

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

2.

No (Applicable only in cases with two
joint sponsors)

Family Member 1
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

4.d. Relationship to Sponsored Immigrant

4.f.

2.d. Relationship to Sponsored Immigrant

2.f.

4.c. Middle Name

4.e. Date of Birth

2.c. Middle Name

2.e. Date of Birth

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

DRAFT - Not For Production

I am sponsoring the following family members
immigrating at the same time or within 6 months of
the principal immigrant named in Part 2. Do not
include any relative listed on a separate visa petition.

Family Member 3

(mm/dd/yyyy) ►

Alien Registration Number (A-Number)
► A-

(mm/dd/yyyy) ►

Alien Registration Number (A-Number)
► A-

Family Member 4
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
5.d. Relationship to Sponsored Immigrant

Family Member 2
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

5.e. Date of Birth
5.f.

3.c. Middle Name
3.d. Relationship to Sponsored Immigrant

3.e. Date of Birth
3.f.

(mm/dd/yyyy) ►

Alien Registration Number (A-Number)
► A-

(mm/dd/yyyy) ►

Alien Registration Number (A-Number)
► A-

Family Member 5
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Middle Name

Form I-864 03/08/12 N

Page 2 of 9

For
USCIS
Use
Only

Part 3. Information on the Immigrant(s) You Are Sponsoring (continued)
Family Member 5 (Continued)

DRAFT - Not For Production

6.d. Relationship to Sponsored Immigrant

7.

6.e. Date of Birth
6.f.

(mm/dd/yyyy) ►

Alien Registration Number (A-Number)
► A-

Part 4. Information on the Sponsor
Sponsor's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

3.b. Apt.

2.a. Street Number
and Name

2.f.

Postal Code

2.g. Province
2.h. Country

Form I-864 03/08/12 N

3.d. State
3.f.

Flr.

Flr.

3.e. Zip Code

Postal Code

3.g. Province
3.h. Country

2.c. City or Town
2.d. State

Ste.

3.c. City or Town

Sponsor's Mailing Address

Ste.

Sponsor's Place of Residence

3.a. Street Number
and Name

1.c. Middle Name

2.b. Apt.

Enter the total number of immigrants you
are sponsoring on this form from Items 1
through 6.

2.e. Zip Code

Other Information

4.

Telephone Number

5.

Country of Domicile

6.

Date of Birth

(

)

-

(mm/dd/yyyy) ►

Page 3 of 9

For
USCIS
Use
Only

Part 4. Information on the Sponsor (continued)
7.

9.

10.

Citizenship/Residency

State or Province of Birth

Country of Birth

U.S. Social Security Number (Required)
►

Part 5. Sponsor's Household Size
Your Household Size - DO NOT COUNT ANYONE TWICE
Persons you are sponsoring in this affidavit:
1.

Enter the number you entered on line 7 of Part 3.

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.

Part 6. Sponsor's Income and Employment
I am currently:
1.

Employed as a/an

1.a.

Name of Employer #1 (if applicable)

1.b.

Name of Employer #2 (if applicable)

Form I-864 01/31/13 N

DRAFT - Not For Production

8.

City or Town of Birth

11.a.

I am a U.S. citizen.

11.b.

I am a U.S. national (for joint sponsors only).

11.c.

I am a lawful permanent resident.
My alien registration number is:
► A-

Military Service (To be completed by petitioner sponsors only.)
12.

I am currently on active duty in the U.S. armed services.
Yes
No

5.

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

6.

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.

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 lines 1-7 and enter the number
here. Household Size:

2.

Self-employed as a/an

3.

Retired from:

3.a.

Company Name

3.b.

Date of Retirement
(mm/dd/yyyy) ►

Page 4 of 9

Household Size
2
1
3
4
5
6
7
8
9
Other

For
USCIS
Use
Only

Poverty Guideline

Remarks

Year: 2 0 Y Y
Poverty Line:
$

4.

5.

Unemployed since
(mm/dd/yyyy) ►
My current individual annual income is:
(See Instructions)
$

Income you are using from any other person who was
counted in your household size, including, in certain
conditions, the intending immigrant. (See Instructions.) Please
indicate name, relationship and income.
Person 1
6.a. Name

6.b. Relationship

6.c. Current Income

$

Person 2
7.a. Name

7.b. Relationship

7.c. Current Income

$

DRAFT - Not For Production

Part 6. Sponsor's Income and Employment (continued)

Person 4

9.a. Name

9.b. Relationship

9.c. Current Income
10.

8.a. Name

8.b. Relationship

8.c. Current Income

Form I-864 01/31/13 N

My current Annual Household Income (Total all lines
from 5, 6.c., 7.c., 8.c., and 9.c. Will be Compared to
Poverty Guidelines -- See Form I-864P.)
$

11.

The person(s) listed in 6.a., 7.a., 8.a., and 9.a. have
completed Form I-864A. I am filing along with this
form all necessary Forms I-864A completed by these
persons.

12.

The person(s) listed in 6.a., 7.a., 8.a., or 9.a. does not
need to complete Form I-864A because he/she is the
intending immigrant and has no accompanying
dependents.
Name(s)

Federal income tax return information
13.

Person 3

$

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.

$

Page 5 of 9

For
USCIS
Use
Only

Household Size
2
1
3
4
5
6
7
8
9
Other

Poverty Guideline

Sponsor's Household Income

Year: 2 0 Y Y
Poverty Line:
$

$
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.

My total income (adjusted gross income on IRS Form
1040EZ) as reported on my Federal tax returns for the
most recent 3 years was:
Tax Year

Total Income
(most recent)

13.a.1. $

13.b.

(2nd most recent) 13.b.1. $

13.c.

(3rd most recent) 13.c.1. $

14.

DRAFT - Not For Production

Part 6. Sponsor's Income and Employment
(continued)

13.a.

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

Part 7. Use of Assets to Supplement Income
(optional)

If your income, or the total income for you and your household,
from Part 6, line 10 exceeds the Federal Poverty Guidelines for
your household size, YOU ARE NOT REQUIRED to complete
this Part. Skip to Part 8.
Your assets (Optional)
1.

2.

Remarks

(Page 5, Line 10)

Enter the balance of all savings and checking accounts.
$
Enter the net cash value of real-estate holdings. (Net
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
lines 1 or 2.
$

4.

Add together lines 1-3 and enter the number here.

Part 7. Use of Assets to Supplement Income
(optional) (continued)

Assets from Form I-864A, line 12d 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 lines
1.a. - 1.c. in Part 2.
6.

Enter the balance of the sponsored immigrant's savings
and checking accounts.
$

7.

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

8.

Enter the current cash value of the sponsored immigrant's
stocks, bonds, certificates of deposit, and other assets not
included on line 6 or 7.
$

9.

Add together lines 6-8 of Part 7 and enter the number
here.
$

Total value of assets.
10.

Add together lines 4, 5.b., and 9 of Part 7 and enter the
number here.
TOTAL: $

TOTAL: $

Form I-864 01/31/13 N

Page 6 of 9

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?

DRAFT - Not For Production

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.
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.

Form I-864 01/31/13 N

Page 7 of 9

Part 8. Sponsor's Contract (continued)
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.

DRAFT - Not For Production

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:
1. Becomes a U.S. citizen;

2. Has worked, or can be credited with, 40 quarters of coverage under the Social Security Act;
3. No longer has lawful permanent resident status, and has departed the United States;
4. 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
5. 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.

I,
(Print Sponsor's Name)
certify under penalty of perjury under the laws of the United
States that:
a.
b.
c.

I know the contents of this affidavit of support that I
signed.
All the factual statements in this affidavit of support
are true and correct.
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

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.

1.a. Signature of Sponsor

1.b. Date of Signature (mm/dd/yyyy) ►

Form I-864 01/31/13 N

Page 8 of 9

Part 9. Information on Preparer, If Prepared By Someone Other Than the Sponsor
Preparer's Full Name

Preparer's Contact Information

Provide the following information concerning the preparer:

4.

Preparer's Daytime Phone Number

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

2.

Preparer's Business or Organization Name

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.f.

Preparer's Email Address

6.

Business State ID # (if any)

)

-

Declaration
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.
7.a. Signature
of Preparer

3.c. City or Town
3.d. State

5.

DRAFT - Not For Production

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

(

3.e. Zip Code

Postal Code

3.g. Province
3.h. Country

Form I-864 01/31/13 N

7.b. Date of Signature (mm/dd/yyyy) ►

Page 9 of 9