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

Request for Exemption for Intending Immigrant's Affidavit
of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-864W

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:

DRAFT
NOT FOR
PRODUCTION
06/19/2017

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 or
G-28I is attached.

Location:

Date (mm/dd/yyyy):

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

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

4.d. State
4.f.

Mailing Address

Ste.

Flr.

4.e. ZIP Code

Province

4.g. Postal Code

2.a. In Care Of Name

4.h. Country

2.b. Street Number
and Name

Ste.

Flr.

2.d. City or Town
2.e. State

Apt.

4.c. City or Town

1.c. Middle Name

Apt.

4.a. Street Number
and Name

4.b.

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

2.c.

Physical Address

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)
► A-

10.

USCIS Online Account Number (if any)
►

11.

U.S. Social Security Number (Required)
►

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.

Form I-864W 07/02/15 N

Other Information

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.)

DRAFT
NOT FOR
PRODUCTION
06/19/2017

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 certify, under penalty of perjury, that all of the information in
my request and any document submitted with it were provided
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my request, and
that all of this information is complete, true, and correct.

NOTE: Read 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.b.

I can read and understand English, and I have read
and understand every question and instruction on this
request and my answer to every question.
The interpreter named in Part 4. read to me every
question and instruction on this request and my
answer to every question in
a language in which I am fluent, and I understood
everything.

2.

Form I-864W 07/02/15 N

In addition, I authorize the Social Security Administration
(SSA) to release information about me in its records to USCIS
and DOS.

Requestor's Signature

6.a. Requestor's Signature

,

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 DOS may deny your request.

At my request, the preparer named in Part 5.,
prepared this request for me based only upon
information I provided or authorized.

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that U.S. Citizenship and Immigration Services (USCIS) or the
U.S. Department of State (DOS) may require that I submit
original documents to USCIS or DOS at a later date.
Furthermore, I authorize the release of any information from
any and all of my records that USCIS or DOS 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 DOS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

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

1.a.

Requestor's Declaration and Certification

,

Page 2 of 5

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

Interpreter's Signature
7.a. Interpreter's Signature

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

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

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NOT FOR
PRODUCTION
06/19/2017

1.b. Interpreter's Given Name (First Name)
2.

Interpreter's Business or Organization Name (if any)

Part 5. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor

Provide the following information about the preparer.

Preparer's Full Name

Interpreter's Mailing Address

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

3.a. Street Number
and Name

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

3.b.

Apt.

Ste.

Flr.

2.

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

Province

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Preparer's Mailing Address

3.g. Postal Code

3.a. Street Number
and Name

3.h. Country

3.b.

Apt.

Ste.

Flr.

3.c. City or Town

Interpreter's Contact Information

3.d. State

4.

Interpreter's Daytime Telephone Number

3.f.

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 3., Item Number
1.b., and I have read to this requestor in the identified language
every question and instruction on this request and his or her
answer to every question. The requestor informed me that he or
she understands every instruction, question, and answer on the
request, including the Requestor's Declaration and
Certification, and has verified the accuracy of every answer.
Form I-864W 07/02/15 N

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Page 3 of 5

Part 5. Contact Information, Declaration, 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.

DRAFT
NOT FOR
PRODUCTION
06/19/2017

NOTE: If you are an attorney or accredited representative you
may be obliged to submit a completed Form G-28, Notice of
Entry of Appearance as Attorney or Accredited Representative,
or G-28I, Notice of Entry of Appearance as Attorney In Matters
Outside the Geographical Confines of the United States, with
this request.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this request at the request of the requestor. The
requestor then reviewed this completed request and informed
me that he or she understands all of the information contained
in, and submitted with, his or her request, including the
Requestor's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
request based only on information that the requestor provided to
me or authorized me to obtain or use.

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

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

Form I-864W 07/02/15 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. Type or print 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.

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PRODUCTION
06/19/2017

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

1.c. Middle Name
2.

A-Number (if any)

► A-

3.a. Page Number
3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-864W 07/02/15 N

4.c. Item Number

7.a. Page Number
7.d.

Page 5 of 5