I-864W Form TOC

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0075

6/19/2017

Reason for Revision: Update to standard language.

Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or accredited representative (if any).	[page 1] [new] START HERE - Type or print in black ink.	[page 1] To be completed by an attorney or accredited representative (if any). [ ] Select this box if Form G-28 or G-28I is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink.
Page 1, Part 1. Information About You or Your Adopted Child (Intending Immigrant)	[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. 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 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] [no change] 10. USCIS Online Account Number (if any) [no change]
Page 2, Part 2. Reason for Exemption	[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 2] [no change]
Page 2, Part 3. Requestor's (Intending Immigrant's) Statement, Contact Information, Certification, and Signature	[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 box], 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 box], 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 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 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.	[page 2] Part 3. Requestor's (Intending Immigrant's) Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-864W Instructions before completing this part. [no change] 1.a. [ ] 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. 1.b. [ ] The interpreter named in Part 4. read to me every question and instruction on this request and my answer to every question in [fillable box], a language in which I am fluent, and I understood everything. 2. [ ] At my request, the preparer named in Part 5., [Fillable Filed], prepared this request for me based only upon information I provided or authorized. [no change] Requestor's Declaration and Certification 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. 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. In addition, I authorize the Social Security Administration (SSA) to release information about me in its records to USCIS and DOS. [no change] 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.
Page 3, Part 4. Interpreter's Contact Information, Certification, and Signature	[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 I certify that: I am fluent in English and [fillable box], 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)	[page 3] [no change] 5. Interpreter’s Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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. Interpreter's Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)
Pages 3-4, Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this Request, If Other than the Requestor	[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. 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) [page 4] 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)	[page 3] Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other than the Requestor [no change] 5. Preparer's Mobile Telephone Number (if any) [no change] [page 4] 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. [no change] 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. [no change]
Page 5, Part 6. Additional Information	[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. Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [fillable lines] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [fillable lines] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [fillable lines] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [fillable lines]	[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. 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. [deleted] [no change] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [fillable lines]

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