Table of Changes I-864EZ Form

Form I-864EZ, Form TOC

Affidavit of Support Under Section 213A of the Act

OMB Number: 1615-0075

Date: 5/04/2015

Reason for Revision: Updates to format and standard language, and edits provided by subject matter experts

Location	Current Text	Proposed Text
Format	Full page format	All italics deleted throughout form, except for sub-headers (e.g., (mm/dd/yyyy) will now be shown (mm/dd/yyyy)). 2 D BC format
Page 1, Part 1. Qualifying to use Form I-864EZ	START HERE. Type or print in black ink. 1.a. I am the petitioner of the family member sponsored on this form. __Yes __No (Use Form I-864) 1.b. I am using my own earned or retirement income which is documented using IRS Form W-2. __Yes __ No (Use Form I-864) 1.c. The sponsored immigrant is the only person immigrating based on the underlying visa petition. __ Yes __No (Use Form I-864)	[Page 1] START HERE. Type or print in black ink. Part 1. Qualifying to Use Form I-864EZ 1.a. I am the petitioner of the family member sponsored on this affidavit. __Yes __No (Use Form I-864) 1.b. I am using my own earned or retirement income which is documented using Internal Revenue Service (IRS) Form W-2. __Yes __ No (Use Form I-864) [no change]
Page 1, Part 2. Information on the immigrant you are sponsoring	Name of Immigrant Last Name First Name Middle Name Mailing Address Street Number and Name (include apartment number) City State or Province Zip/Postal Code Country Telephone Number (Include area code or country and city codes) Date of Birth (mm/dd/yyyy) Alien Registration Number (if any) A- Social Security Number (if any)	[Page 1] Part 2. Information About the Immigrant You Are Sponsoring (Intending Immigrant) Name of Immigrant 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name (if any) Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country Other Information 3. Daytime Telephone Number 4. Date of Birth (mm/dd/yyyy) 5. Alien Registration Number (A-Number) (if any) A- 6. USCIS ELIS Account Number (if any) 7. U.S. Social Security Number (if any)
Page 2, Part 3. Information on the Sponsor (You)	Name of Sponsor Last Name First Name Middle Name Mailing Address Street Number and Name (include apartment number) City State or Province Zip/Postal Code Country Place of Residence (if different from mailing address) Street Number and Name (include apartment number) City State or Province Zip/Postal Code Country Country of Domicile Country Date of Birth (mm/dd/yyyy) Place of Birth City State or Province Country U.S. Social Security Number (required) Citizenship/Residency ___I am a U.S. citizen __I am a Lawful Permanent Resident. My alien registration number is A – Military Service I am currently on active duty in the U.S. armed services. Yes/No	[Page 1] Part 3. Information About You (Sponsor) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name (if any) Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country 3. Is your current mailing address the same as your physical address? __ Yes __No If you answered “No” to Item Number 3., provide your physical address below. Physical Address 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. ZIP Code 4.f. Province 4.g. Postal Code 4.h. Country Other Information 5. Country of Domicile 6. Date of Birth (mm/dd/yyyy) 7. City or Town of Birth 8. State or Province of Birth (if applicable) 9. Country of Birth 10. U.S. Social Security Number (Required) 11. USCIS ELIS Account Number (if any) Citizenship or Nationality 12.a. __I am a U.S. citizen 12.b. __I am a lawful permanent resident. 12.c. __ My alien registration number is: 12.d.__I am a U.S. National 13. Military Service I am currently on active duty in the United States Armed Forces or U.S. Coast Guard. __Yes __No
Page 2, Sponsor’s household size.	Your Household Size- Do not count anyone twice. Yourself and the person you are sponsoring on this form. Your spouse. Your dependent children under age 21. If you have sponsored any other persons on an I-864 who are now lawful permanent residents in the United States, enter the number here. If you have any other dependents listed on you most recent Federal Income tax return, enter the number here. Add together lines a, b, c, d and e and enter the number here. This is your HOUSEHOLD SIZE for the purposes of this form.	[Page 2] Part 4. Information About Your Household Size NOTE: Do not count any household member more than once. 1.a. Yourself and the person you are sponsoring on this Form I-864EZ. 1. b. Your spouse. 1. c. Your dependent children under 21 years of age. 1.d. If you have sponsored any other persons on a Form I-864 who are now lawful permanent residents in the United States, enter the number here. 1. e. If you have any other dependents listed on you most recent Federal Income tax return, enter the number here. 1.f. Add together Item Numbers 1.a.-1.e. and enter the number here. This is your HOUSEHOLD SIZE for the purposes of this Form I-864EZ.
Page 3, Part 5. Sponsor’s income and employment.	I am currently: Employed as a/an Name of Employer (if applicable) Name of Second Employer (if applicable) Retired since (mm/dd/yyyy) Name of Former Employer My individual annual income is currently: Federal income tax 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. (Optional) I have attached photocopies or transcripts of my Federal tax returns for my second and third most recent tax years. 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) $_________	[Page 3] Part 5. Information About Your Employment and Income I am currently: __ Employed (Complete Item Numbers 2.a.-2.c.) __Retired (Complete Item Numbers 3.a.-3.b.) 2.a. Current Occupation 2.b. Name of Employer 1 (if applicable)__________ 2.c. Name of Employer 2 (if applicable)__________ 3.a. Name of Former Employer___________ 3.b. Date of Retirement (mm/dd/yyyy)_______ 4. My current individual annual income $_________ Federal Income Tax Information 5.a. Have you filed a Federal 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. 5.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 IRS Form 1040EZ) as reported on my Federal income tax returns for the most recent three years was: Tax Year Total Income 6.a. Most Recent _____ $_________ 6.b. 2nd Most Recent _____ $_________ 6.c. 3rd Most Recent ______ $_________
Page 4, Part 6. Sponsor’s Contract	Please note that, by signing this Form I-864EZ, 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-864EZ. 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-864EZ? If you sign a Form I-864EZ 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-864EZ 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-864EZ? You cannot be made to sign a Form I-864EZ if you do not want to do so. But if you do not sign the Form I-864EZ, the intending immigrant may not be able to become a permanent resident in the United States. What Does Signing the Form I-864EZ Require Me to Do? If an intending immigrant becomes a permanent resident in the United States based on a Form I-864EZ that you have signed, then, until your obligations under the Form I-864EZ 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-864EZ that you have signed, then until your obligations under the Form I-864EZ 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-864EZ 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-864EZ 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-864EZ will end if the person who becomes a permanent resident based on a Form I-864EZ 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-864EZ. Your obligations under a Form I-864EZ 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, _________________, 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 6, 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 immigrant indicated in Part 2 to become a permanent resident 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 other evidence submitted is true and correct. 21. (Sponsor’s Signature) Date- mm/dd/yyyy	[Page 3] Part 6. 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. By signing this Form I-864EZ, 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-864EZ. If you do not understand the obligations, you may wish to consult an attorney or accredited representative. What Is the Legal Effect of Signing Form I-864EZ? If you sign Form I-864EZ on behalf of any person (intending immigrant) who is applying for an immigrant visa or adjustment of status to a lawful permanent resident, and that intending immigrant submits Form I-864EZ 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 foreign national likely to become a public charge, the U.S. Government can consider your income and assets available to be available for the support of the intending immigrant. What If I Choose Not To Sign Form I-864EZ? You cannot be made to sign Form I-864EZ if you do not want to do so. But if you do not sign Form I-864EZ, the intending immigrant may not be able to become a lawful permanent resident in the United States. What Does Signing Form I-864EZ Require Me to Do? If an intending immigrant becomes a lawful permanent resident in the United States based on a Form I-864EZ that you have signed, then, until your obligations under Form I-864EZ 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 (or 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.) 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. Please see the USCIS Web site at www.uscis.gov/I-865 for more information on filing a change of address as a sponsor. What Other Consequences Are There? If an intending immigrant becomes a lawful permanent resident in the United States based on a Form I-864EZ that you have signed, then until your obligations under Form I-864EZ terminate, your income and assets may be considered 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 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 the Form I-864EZ 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 lawful permanent resident based on the Form I-864EZ 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. Please see the USCIS Web site at www.uscis.gov/I-865 for more information on filing a change of address as a sponsor. When Will These Obligations End? Your obligations under Form I-864EZ will end if the person who becomes a lawful permanent resident based on a Form I-864EZ that you signed: Becomes a U.S. Citizen; Has worked, or can receive credit for 40 quarters of coverage under the Social Security Act (SSA); 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: Divorce does not terminate your obligations under this Form I-864EZ. Your obligations under Form I-864EZ 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. [new] 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 ­7. 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. 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 immigration 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 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: I know the contents of this affidavit of support that I signed; [deleted- already above] I have read and I understand each of the obligations described in Part 6, 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 immigrant indicated in Part 2 to become a lawful permanent resident of the United States; 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-864EZ; 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; 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-864EZ; and I authorize the Social Security Administration to release information about me in its records to the Department of State and USCIS. [Deleted- already above] 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 affidavit.
		[Page 5] [new] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. 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) Interpreter’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 Interpreter’s Contact Information 4. Interpreter’s Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 6., Item Number 1.b.; I have read to this sponsor every question and instruction on this affidavit, as well as the answer to every question, in the language provided in Part 6., Item Number 1.b.; and The sponsor has informed me that he or she understands every instruction and question on the affidavit, as well as the answer to every question, and the sponsor verified the accuracy of every answer. Interpreter’s Signature 6.a. Interpreter’s Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 5, Part 7. 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: Date (mm/dd/yyyy): Printed Name: Firm Name: Address: Telephone Number: E-Mail Address: Business State ID # (if any)	[Page 6] Part 8. Contact Information, Statement, Certification, and Signature of the Person Preparing this Affidavit, If Other Than the Sponsor Provide the following information about the preparer. 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 Fax Number 6. Preparer’s Email Address (if any) 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 [Sub-header] 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy) [see above]
		[Page 7] [new] Part 9. Additional Information If you need extra space to provide any additional information within this affidavit, 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 affidavit 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. 1.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. ________________________________ 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. ________________________________ 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. ________________________________ 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. ________________________________ 7.a. Sponsor’s Signature 7.b. Date of Signature (mm/dd/yyyy)

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