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

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

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.)
Last Name

1. Name

2. Address

Draft

First Name

For Government
Use Only

Middle Name

Street Number and Name (include apartment number)
City
Country

State or Province

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

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)

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 (09/19/11) Y