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

Request for Exemption for
Intending Immigrant's Affidavit of Support

USCIS
Form I-864W

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

OMB No. 1615-0075
Expires 03/31/2015

For Government Use Only
This Form I-864W:
DOES NOT MEET
the requirements of
exemption

MEETS the
requirements
of exemption

Reviewed By:
Location:

Date (mm/dd/yyyy):

► START HERE - Type or print in black ink.

Part 1. Information About You or Your Adopted
Child (Intending Immigrant)

Physical Address
4.a. Street Number
and Name

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Name of Requestor

4.b

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

Apt.

Ste.

4.c. City or Town
4.d. State

1.c. Middle Name

4.f.

4.e. ZIP Code

Province

Mailing Address

4.g. Postal Code

2.a. In Care Of Name

4.h. Country

2.b. Street Number
and Name

Other Information

2.c.

Apt.

Ste.

Flr.

2.d. City or Town
2.e. State
2.g. Province
2.h. Postal Code
2.i.

3.

Country

Flr.

2.f.

5.

Date of Birth (mm/dd/yyyy)

6.

City or Town of Birth

7.

State or Province of Birth (if applicable)

8.

Country of Birth

9.

Alien Registration Number (A-Number) (if any)

ZIP Code

Is your current mailing address the same as your physical
address?
Yes
No

► A10.

USCIS ELIS Account Number (if any)
►

If you answered "No" to Item Number 3., provide your
physical address.
11.

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

Form I-864W 10/18/13 N

Page 1 of 5

Part 2. Reason for Exemption

Requestor's Contact Information

I am EXEMPT from filing Form I-864, Affidavit of Support
Under Section 213A of the INA, because:

3.

Requestor's Daytime Telephone Number

4.

Requestor's Mobile Telephone Number (if any)

5.

Requestor's Email Address (if any)

1.a.

1.b.

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 years of age, 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.

1.c.

I am filing for an immigrant visa or adjustment of
status as a self-petitioning widow(er) using Form
I-360, Petition for Amerasian, Widow(er), or Special
Immigrant.

1.d.

I am filing for an immigrant visa or adjustment of
status as a battered spouse or child using Form I-360.

I furthermore authorize release of information contained in this
request, in supporting documents, and in my USCIS or the
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws.

NOTE: Read the information on penalties in the Penalties
section of the Form I-864W Instructions before completing this
part.

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.

I can read and understand English, and have read and
understand every question and instruction on this
request, as well as my answer to every question.

The interpreter named in Part 4. has also read to me
every question and instruction on this request, as well
as my answer to every question, in

,
a language in which I am fluent. I understand every
question and instruction on this request as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
2.

I certify, under penalty of perjury, that the information in my
request and any document submitted with my request were
provided by me and are complete, true, and correct.
In addition, I authorize the Social Security Administration (SSA)
to release information about me in its records to the Department
of State and U.S. Citizenship and Immigration Services.

Requestor's Statement

1.b.

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS or the Department of State may require that I submit
original documents to USCIS or the Department of State at a
later date. Furthermore, I authorize the release of any
information from any and all of my records that USCIS or the
Department of State may need to determine my eligibility for
the immigration benefit that I seek.

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Part 3. Requestor's (Intending Immigrant's)
Statement, Contact Information, Certification,
and Signature

1.a.

Requestor's Certification

Requestor's Signature

6.a. Requestor's Signature (or U.S. citizen parent, if intending
immigrant is less than 14 years of age)

6.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL REQUESTORS: If you do not completely
fill out this request or fail to submit required documents listed
in the instructions, USCIS or the Department of State may deny
your request.

I have requested the services of and consented to
,
who
is
is not an attorney or accredited
representative, preparing this request for me.

Form I-864W 10/18/13 N

Page 2 of 5

Part 4. Interpreter's Contact Information,
Certification, and Signature

Interpreter's Signature
6.a. Interpreter's Signature

Provide the following information about the interpreter.
6.b. Date of Signature (mm/dd/yyyy)

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

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

2.

Interpreter's Business or Organization Name (if any)

Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Request, If Other than the
Requestor
Provide the following information about the preparer.

Preparer's Full Name

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Interpreter's Mailing Address

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

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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

Province

3.g. Postal Code
3.h. Country

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

2.

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Preparer's Mailing Address

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

3.d. State
3.f.

5.

Interpreter's Email Address (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Certification
I certify that:

Preparer's Contact Information

,
I am fluent in English and
which is the same language provided in Part 3., Item Number
1.b.;

4.

Preparer's Daytime Telephone Number

I have read to this requestor every question and instruction on
this request, as well as the answer to every question, in the
language provided in Part 3., Item Number 1.b.; and

5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

The requestor has informed me that he or she understands every
instruction and question on the request, as well as the answer to
every question, and the requestor verified the accuracy of every
answer.
Form I-864W 10/18/13 N

Page 3 of 5

Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Request, If Other than the
Requestor (continued)
Preparer's Statement
7.a.

I am not an attorney or accredited representative but
have prepared this request on behalf of the requestor
and with the requestor's consent.

7.b.

I am an attorney or accredited representative and my
representation of the requestor in this case
extends
does not extend beyond the
preparation of this request.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this request, you must submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, with this
request.

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Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this request on behalf of, at the request
of, and with the express consent of the requestor. I completed
this request based only on responses the requestor provided to
me. After completing the request, I reviewed it and all of the
requestor's responses with the requestor, who agreed with every
answer on the request. If the requestor supplied additional
information concerning a question on the request, I recorded it
on the request.

Preparer's Signature
8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-864W 10/18/13 N

Page 4 of 5

5.a. Page Number

Part 6. Additional Information
If you need extra space to provide any additional information
within this request, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this request or attach a separate sheet
of paper. Include your name and A-Number (if any) at the top
of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet.

5.b. Part Number

5.c. Item Number

5.d.

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

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A-Number (if any)

A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d.

4.b. Part Number

Form I-864W 10/18/13 N

4.c. Item Number

7.a. Requestor's Signature

7.b. Date of Signature (mm/dd/yyyy)

Page 5 of 5