Table of Changes I-864W Form

Form I-864W, Form TOC

Request for Exemption for Intending Immigrant’s Affidavit of Support

OMB Number: 1615-0075

Date: 5/04/2015

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

Location	Current Text	Proposed Text
Page 1, Part 1. Part 1. Information about the intending immigrant. (You or your adopted child.)	1. Name Last Name First Name Middle Name 2. Address Street Number and Name (include apartment number) City State or Province Country Zip/Postal Code 3. Date of Birth (mmddyyyy) 4. Country of Birth (city/country) 5. Telephone Number (Include area code or country and city codes) 7. Alien Registration Number (if any) 6. Social Security Number (if any)	[Page 1] Part 1. Information About You or Your Adopted Child (Intending Immigrant) Name of Requestor 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. [Fillable Field] 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? If you answered “No” to Item Number 3., provide your physical address. 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. Date of Birth (mm/dd/yyyy) 6. City or Town of Birth 7. State or Province of Birth (if applicable) 8. Country of Birth [Deleted] 9. Alien Registration Number (A-Number) (if any) 10. USCIS ELIS Account Number (if any) 11. U.S. Social Security Number (if any)
Page 1, 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.	[Page 2] Part 2. Reason for Exemption I am EXEMPT from filing Form I-864, Affidavit of Support Under Section 213A of the INA, because: 1.a. 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.) 1.b. 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.
Page 1, Part 3. Concluding provision.	I, [Fillable Field], certify under penalty of perjury under the laws of the United States that: I know the contents of this exemption request which I signed; All the statements in this exemption request are true and correct; and 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)	[Page 2] Part 3. Requestor’s (Intending Immigrant’s) Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-864W Instructions before completing this part. Requestor’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 request, as well as my answer to every question. 1.b. 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 [Fillable Field], 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 have requested the services of and consented to [Fillable Field], who is/is not an attorney or accredited representative, preparing this request for me. Requestor’s Contact Information 3. Requestor’s Daytime Telephone Number 4. Requestor’s Mobile Telephone Number (if any) 5. Requestor’s Email Address (if any) Requestor’s Certification [Sub-header] 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 may need to determine my eligibility for the immigration benefit that I seek. 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. 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 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.
New		[Page 3] Part 4. 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 [Sub-header] I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 3., Item Number 1.b.; 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 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. Interpreter’s Signature 6.a. Interpreter’s Signature 6.b. Date of Signature (mm/dd/yyyy)
New		[Page 3] 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 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. [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) 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. 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)
New		[Page 5] 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. 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. [Fillable Field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable Field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable Field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable Field] 7.a. Requestor’s Signature 7.b. Date of Signature (mm/dd/yyyy)

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