Pages
2-3,
Part
3. Information on the Immigrant(s) You Are Sponsoring
|
[Page
2]
Part
3. Information on the Immigrant(s) You Are Sponsoring
1.
I am sponsoring the principal immigrant named in Part
2.
Yes
No (Applicable only in cases with two joint sponsors)
2.
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 1
2.a.
Family
Name (Last Name)
2.b.
Given Name (First Name)
2.c.
Middle Name
2.d.
Relationship to Sponsored Immigrant
2.e.
Date of Birth (mm/dd/yyyy)
2.f.
Alien Registration Number (A-Number)
Family
Member 2
3.a.
Family
Name (Last Name)
3.b.
Given Name (First Name)
3.c.
Middle Name
3.d.
Relationship to Sponsored Immigrant
3.e.
Date
of Birth (mm/dd/yyyy)
3.f.
Alien
Registration Number (A-Number)
Family
Member 3
4.a.
Family
Name (Last Name)
4.b.
Given Name (First Name)
4.c.
Middle Name
4.d.
Relationship to Sponsored Immigrant
4.e.
Date of Birth (mm/dd/yyyy)
4.f.
Alien Registration Number (A-Number)
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
5.e.
Date of Birth (mm/dd/yyyy)
5.f.
Alien Registration Number (A-Number)
Family
Member 5
6.a.
Family
Name (Last Name)
6.b.
Given Name (First Name)
6.c.
Middle Name
[Page
3]
6.d.
Relationship to Sponsored Immigrant
6.e.
Date of Birth (mm/dd/yyyy)
6.f.
Alien Registration Number (A-Number)
7.
Enter the total number of immigrants you are sponsoring on this
form from Items
1-6.
|
[Page
2]
Part
3. Information About
the Immigrants
You Are Sponsoring
1.
I am sponsoring the principal immigrant named in Part
2.
Yes
No (Applicable only if
you are sponsoring family members in Part
3.
as the second joint
sponsor)
2.
I am sponsoring the following family members immigrating at the
same time or within six
months of the principal immigrant named in Part
2.
(Do
not
include any relative listed on a separate visa petition.)
Family
Member 1
3.a.
Family
Name (Last Name)
3.b.
Given Name (First Name)
3.c.
Middle Name
4.
Relationship to Sponsored Immigrant
5.
Date
of Birth (mm/dd/yyyy)
6.
Alien
Registration Number (A-Number) (if
any)
7.
USCIS ELIS Account Number (if
any)
Family
Member 2
8.a.
Family
Name (Last Name)
8.b.
Given Name (First Name)
8.c.
Middle Name
9.
Relationship to Sponsored Immigrant
10.
Date
of Birth (mm/dd/yyyy)
11.
Alien
Registration Number (A-Number) (if
any)
12.
USCIS ELIS Account Number (if
any)
Family
Member 3
13.a.
Family
Name (Last Name)
13.b.
Given Name (First Name)
13.c.
Middle Name
14.
Relationship
to Sponsored Immigrant
15.
Date
of Birth (mm/dd/yyyy)
16.
Alien
Registration Number (A-Number) (if
any)
17.
USCIS ELIS Account Number (if
any)
Family
Member 4
18.a.
Family
Name (Last Name)
18.b.
Given Name (First Name)
18.c.
Middle Name
[Page
3]
19.
Relationship
to Sponsored Immigrant
20.
Date
of Birth (mm/dd/yyyy)
21.
Alien
Registration Number (A-Number) (if
any)
22.
USCIS ELIS Account Number (if
any)
Family
Member 5
23.a.
Family
Name (Last Name)
23.b.
Given Name (First Name)
23.c.
Middle Name
24.
Relationship
to Sponsored Immigrant
25.
Date
of Birth (mm/dd/yyyy)
26.
Alien
Registration Number (A-Number) (if
any)
27.
USCIS ELIS Account Number (if
any)
28.
Enter
the total number of immigrants you are sponsoring on this
affidavit
from
Item
Numbers 1.a.
- 27.
|
Page
5,
Part
6. Sponsor’s Income and Employment
|
[Page
4]
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)
2.
Self-employed
as a/an
3.
Retired
from:
3.a.
Company
Name
3.b.
Date
of Retirement (mm/dd/yyyy)
[Page
5]
4.
Unemployed since (mm/dd/yyyy)
5.
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
Person
3
8.a.
Name
8.b.
Relationship
8.c.
Current Income
Person
4
9.a.
Name
9.b.
Relationship
9.c.
Current Income
10.
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 person(s).
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.
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
6]
My
total income (adjusted gross income on IRS Form 1040EZ) as
reported on my
Federal
income tax
returns for the most recent 3 years was:
Tax
Year Total Income
13.a
_____ (most recent) 13.a.1
13.b.
(2nd
most recent) 13.b.1.
13.c.
(3rd
most recent) 13.c.1.
14.
(Optional)
I have attached photocopies or transcripts of my Federal tax
returns for my second and third most recent tax years.
|
[Page
5]
Part
6. Sponsor’s Employment
and Income
I
am currently:
1.a.
Employed
as a/an
1.a.1.
Name
of Employer
1
(if applicable)
1.a.2.
Name
of Employer
2
(if applicable)
1.b.
Self
employed as a/an
1.c.
Retired
from
(Company Name)
since
(mm/dd/yyyy)
1.d.
Unemployed
since (mm/dd/yyyy)
2.
My
current individual annual income is:
Income
you are using from any other person who was counted in your
household size,
including, in certain conditions, the intending immigrant. (See
Form I-864 Instructions.) Please indicate name, relationship,
and income.
Person
1
3.
Name
4.
Relationship
5.
Current
Income
Person
2
6.
Name
7.
Relationship
8.
Current
Income
Person
3
9.
Name
10.
Relationship
11.
Current
Income
Person
4
12.
Name
13.
Relationship
14.
Current
Income
15.
My
Current
Annual Household Income (Total
all lines from Part
6., Item Numbers 2., 5.,
8., 11., and
14.;
the
total will
be
compared to Federal
Poverty
Guidelines on
Form
I-864P.)
16.
The
people
listed in Item
Numbers 3.,
6.,
9.,
and 12.
have
completed Form I-864A. I am filing along with this affidavit
all
necessary Form
I-864As completed
by these
people.
[Page
6]
17.
One
or more of the
people
listed in Item
Numbers
3.,
6.,
9.,
and 12.
do
not
need to complete Form I-864A because he or she is the intending
immigrant and has no accompanying dependents.
Name
Federal
Income Tax Return Information
18.a.
Have
you filed a
Federal income
tax
return for each of the three most recent tax years?
Yes
No
NOTE:
You MUST
attach a photocopy or transcript of your Federal income tax return
for only the most recent tax year.
18.b.
(Optional) I
have attached photocopies or transcripts of my Federal income
tax
returns for my second and third most recent tax years.
My
total income (adjusted gross income on (Internal
Revenue Service (IRS) Form
1040EZ) as reported on my
Federal
income tax
returns for the most recent three
years
was:
Tax
Year Total Income
19.a.
Most Recent $
19.b.
2nd
Most Recent $
19.c.
3rd
Most Recent $
20.
I was not required to file a Federal income tax return as my
income was below the IRS required level and I have attached
evidence to support this.
|
Page
6,
Part
7. Use of Assets to Supplement Income (optional)
|
[Page
6]
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)
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.)
Enter
the net cash value of all stocks, bonds, certificates of deposit,
and any other assets not already included in lines 1 or 2.
Add
together lines 1-3 and enter the number here. TOTAL: $_________
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.
Enter
the balance of the sponsored immigrant’s savings and
checking accounts.
Enter
the net cash value of all the sponsored immigrant’s real
estate holdings. (Net means investment value minus mortgage
debt.)
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.
Add
together lines 6-8 of Part 7 and enter the number here.
Total
value of assets.
Add
together lines 4, 5.b., and 9 of Part 7 and enter the number
here.
TOTAL:
|
[Page
6]
Part
7. Use of Assets to Supplement Income (Optional)
If
your income, or the total income for you and your household, from
Part 6.,
Item Numbers 19.a. - 19.c., exceeds
the Federal Poverty Guidelines for your household size, YOU ARE
NOT REQUIRED to complete this Part
7. Skip
to Part 8.
Your
Assets
(Optional)
1.
Enter
the balance of all savings and checking accounts.
2.
Enter
the net cash value of real-estate holdings. (Net value
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 Item
Number 1.
or
Item
Number 2.
4.
Add together Item Numbers 1. -
3.
and enter the number here. TOTAL:
Assets
from Form I-864A, Part
4., Item Number 3.d.,
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 Part
2.,
Item
Numbers 1.a.
- 1.c.
6.
Enter
the balance of the sponsored immigrant’s savings and
checking accounts.
[Page
7]
7.
Enter the net cash value of all the sponsored immigrant’s
real estate holdings. (Net value
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 in
Item
Number 6.
or Item
Number 7.
9.
Add together Item
Numbers 6.
-
8.
and
enter the number here.
Total
Value
of Assets
10.
Add together Item
Numbers 4.,
5.b.,
and 9.
and enter
the number here.
TOTAL:
|
Page
8,
Part
8. Sponsor’s Contract
|
[Page
7]
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 lawful 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 lawful permanent resident in the United
States.
What
Does Signing the Form I-864 Require Me to do?
If
an intending immigrant becomes a lawful 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
lawful permanent resident based on the Form I-864 that you signed,
that person may sue you for this support.
[Page
8]
If
a Federal, State or local agency, or a private agency provided any
covered means-tested public benefit to the person who becomes a
lawful 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:
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:
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 lawful 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 corrects.
1.a.
Signature of the Sponsor
1.b.
Date of Signature (mm/dd/yyyy)
|
[Page
7]
Part
8. Sponsor’s Contract, Statement,
Contact Information, Certification, and Signature
NOTE:
Read the information on penalties in the Penalties
section of the Form I-864 Instructions before completing this
part.
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
(INA)
and
other Federal laws. The following paragraphs describe those
obligations. Please read the following information carefully
before you sign
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
Form
I-864?
If
you sign
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
lawful permanent resident, and that intending immigrant submits
Form I-864
to the U.S. Government with his or her application for an
immigrant visa or adjustment of status, under INA
section
213A,
these actions
create a contract between you and the U.S.
Government.
The intending immigrant
becoming
a lawful
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 a
person likely
to become a public charge, the U.S. Government can consider your
income and assets as
available for the support of the intending immigrant.
What
If I Choose Not to Sign
Form I-864?
The
U.S. Government cannot make you sign Form 1-864
if you do not want to do so. But if you do not sign
Form I-864,
the intending immigrant may not
become
a lawful permanent resident in the United States.
What
Does Signing
Form I-864
Require Me to Do?
If
an intending immigrant becomes a lawful permanent resident in the
United States based on a Form I-864 that you have signed, then,
until your obligations under
Form I-864
terminate, you must:
A.
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 or U.S.
Coast Guard,
and the person is your husband, wife, or
unmarried child under 21
years of age); and
[Page
8]
B.
Notify
U.S.
Citizenship and Immigration Services (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 lawful
permanent
resident in the United States based on a Form I-864 that you have
signed, then, until your obligations under
Form I-864
terminate, the
U.S. Government may consider (deem) your
income and assets
as 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
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
lawful permanent resident based on a
Form
I-864 that you signed, that person may sue you for this support.
If
a Federal,
state, local, or private agency
provided any covered means-tested public benefit to the person who
becomes a lawful permanent resident based on a
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.
[no
change]
[no
change]
When
Will These Obligations End?
Your
obligations under a Form I-864
that you signed will
end if the person who becomes a lawful
permanent
resident based on that
affidavit:
A.
Becomes
a U.S. citizen;
B.
Has
worked, or can receive
credit for, 40
quarters of coverage under the Social Security Act;
C.
No
longer has lawful permanent resident status and has departed the
United States;
D.
Is
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
E.
Dies.
Note
that divorce does
not terminate
your obligations under
Form I-864.
Your
obligations under a Form I-864
that you signed also
end if you die. Therefore, if you die, your estate is
not required
to take responsibility for the person’s support after your
death. However,
your
estate may owe
any
support that you accumulated
before you died.
Sponsor’s
Statement
NOTE:
Select the box for either Item
Number 1.a. or
1.b.
If applicable, select the box for Item
Number 2.
1.a.
I can read and understand English, and have read and understand
every question and instruction on this affidavit,
as well as my answer to every question.
1.b.
The interpreter named in Part
9. has
also read to me every
question and instruction on this affidavit,
as well as my answer to every question, in [Fillable Field], a
language in which I am fluent. I understand every question and
instruction on this affidavit
as
translated to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated above.
[Page
9]
2.
I have requested the services of and consented to [Fillable
Field], who
is/is
not an attorney or accredited representative, preparing this
affidavit
for
me.
Sponsor’s
Contact
Information
3.
Sponsor’s
Daytime
Telephone Number
4.
Sponsor’s
Mobile
Telephone Number (if any)
5.
Sponsor’s
Email
Address (if any)
Sponsor’s
Certification
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 benefit that I seek.
I
furthermore authorize release of information contained in this
affidavit,
in supporting documents, and in my USCIS or
Department of State records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I
certify, under
penalty of perjury,
that the information in my affidavit
and
any document submitted with my affidavit
were
provided by me and are complete, true, and correct, and:
A.
I
know the contents of this affidavit of support that I signed:
[delete]
B.
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 lawful permanent residents of the United States;
C.
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;
D.
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 IRS;
E.
I understand that, if I am related to the sponsored immigrant by
marriage, the termination of the marriage (by divorce,
dissolution, annulment, or other legal process) will not relieve
me of my obligations under this Form I-864;
and
F.
I
authorize the Social Security Administration to release
information about me in its records to the Department of State and
USCIS.
[Deleted]
Sponsor’s
Signature
6.a.
Sponsor’s
Signature
6.b.
Date
of Signature (mm/dd/yyyy)
NOTE
TO ALL SPONSORS: If
you do not completely fill out this affidavit
or
fail to submit required documents listed in the Instructions,
USCIS or
the Department of State may
deny your request.
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Page
9,
Information
on Preparer, If Prepared By someone Other Than the Sponsor
|
[Page
9]
Part
9. Information on Preparer, If Prepared By Someone Other Than the
Sponsor
Preparer’s
Full Name
1.a.
Preparer’s Family Name (Last Name)
1.b.
Preparer’s Given Name (First Name)
2.
Preparer’s Business or Organization Name (if any)
Preparer’s
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
Zip Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Preparer’s
Contact Information
4.
Preparer’s Daytime Telephone Number
5.
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 tis 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
7.b.
Date of Signature (mm/dd/yyyy)
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[Page
10]
Part
10. Contact
Information,
Statement, Certification, and Signature of the Person Preparing
this Affidavit, If Other
Than the Sponsor
Provide
the following information about the preparer.
[no
change]
[Page
11]
Preparer’s
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr. [Fillable Field]
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Preparer’s
Contact Information
4.
Preparer’s Daytime Telephone Number
5.
Preparer’s Fax Number
6.
Preparer’s
Email Address (if
any)
[Deleted]
Preparer’s
Statement
7.a.
I
am not an attorney or accredited representative but have prepared
this affidavit on behalf of the sponsor
and
with the sponsor’s
consent.
7.b.
I
am an attorney or accredited representative and my representation
of the sponsor
in
this case
extends/does not extend
beyond
the preparation of this affidavit.
NOTE:
If
you are an attorney or accredited representative whose
representation extends beyond preparation of this affidavit, you
must submit a completed Form G-28, Notice of Attorney or
Accredited Representative, with this affidavit.
Preparer’s
Certification
By
my signature, I
certify,
swear, or affirm, under
penalty of perjury,
that I prepared this
affidavit
on behalf of, at the request of, and with the express consent of
the sponsor.
I completed this affidavit based only on responses the sponsor
provided to me. After completing the affidavit, I reviewed it and
all of the sponsor’s
responses with the sponsor,
who agreed with every answer on the affidavit. If the sponsor
supplied additional information concerning a question on the
affidavit, I recorded it on the affidavit.
Preparer’s
Signature
8.a.
Preparer’s Signature
8.b.
Date of Signature (mm/dd/yyyy)
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