Declaration of Self-Sufficiency

Instructions for Declaration of Self-Sufficiency
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-944

OMB No. 1615-0142
Expires xx/xx/xxxx

What Is the Purpose of Form I-944?
Form I-944, Declaration of Self-Sufficiency, is used by an individual to demonstrate that he or she is not inadmissible
based on the public charge ground (Immigration and Nationality Act (INA) section 212(a)(4)). An alien is inadmissible
under INA section 212(a)(4) if he or she is more likely than not at any time in the future to receive one or more public
benefits, as defined in 8 CFR 212.21(b), for more than 12 months in the aggregate within any 36-month period (such that,
for instance, receipt of two benefits in one month counts as two months).

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Who Must File Form I-944?

You must file this form if you are filing Form I-485, Application to Register Permanent Residence or Adjust Status, and
you are subject to the public charge ground of inadmissibility.
In general, each applicant who submits Form I-485 must submit his or her own Form I-944 if the applicant is subject to
the public charge ground of inadmissibility.

How Is Form I-944 Used?

Form I-944 is used to determine whether you are inadmissible to the United States under INA section 212(a)(4) because
there is a likelihood that you will become a public charge at any time in the future. We evaluate whether you are
inadmissible by weighing all the positive and negative factors related to your age, health, family status, assets, resources
and financial status, education and skills, prospective immigration status and period of stay. We also consider a Form
I-864, Affidavit of Support Under Section 213A of the Act, if you are required to submit Form I-864 as part of your
adjustment of status application. For more information on Form I-864, see www.uscis.gov/i-864.

Who Is Exempt from Filing Form I-944?
If you are exempt from the public charge ground of inadmissibility, you do not need to file Form I-944.
If you are applying for adjustment of status to that of a lawful permanent resident, you are exempt from the public charge
ground of inadmissibility if you are adjusting:
1. As a VAWA self-petitioner;
2. As a Special Immigrant Juvenile;
3. As a Certain Afghan or Iraqi national;
4. As an Asylee;
5. As a Refugee;
6. As a victim of qualifying criminal activity (U Nonimmigrant) under INA section 245(m);
7. Under any category other than INA section 245(m) but you are in valid U nonimmigrant status at the time you file
your application for adjustment of status. (This exemption only applies if, at the time of the adjudication of the Form
I-485, you are still in valid U nonimmigrant status. If, at the time of adjudication of the Form I-485, you are no longer
in valid U nonimmigrant status, you may be required to submit a Form I-944 and a Form I-864).
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8. As a victim of human trafficking (T nonimmigrant) under section 245(l) of the INA;
9. Under any category other than INA section 245(l), but you either have a pending application for T nonimmigrant
status (Form I-914) that sets forth a prima facie case for eligibility, or are in valid T nonimmigrant status at the time
you file your application for adjustment of status. (This exemption only applies if your Form I-914 is still pending
and deemed to be prima facie eligible, or you are in valid T nonimmigrant status when we adjudicate your adjustment
of status application);
10. Under the Cuban Adjustment Act;
11. Under the Cuban Adjustment Act for battered spouses and children;
12. Based on dependent status under the Haitian Refugee Immigrant Fairness Act;

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13. Based on dependent status under the Haitian Refugee Immigrant Fairness Act for battered spouses and children;
14. As a Lautenberg Parolee;

15. Under the Indochinese Parole Adjustment Act of 2000;

16. Based on continuous residence in the United States since before January 1, 1972 (“Registry”);
17. Under the Amerasian Homecoming Act;
18. As a Polish or Hungarian Parolee;

19. As Nicaraguans and other Central Americans under section 203 of the Nicaraguan Adjustment and Central American
Relief Act (NACARA);
20. As an American Indian Born in Canada (INA section 289) or the Texas Band of Kickapoo Indians of the Kickapoo
Tribe of Oklahoma, Pub. L. 97-429 (Jan. 8, 1983); or
21. As a spouse, child, or parent of a deceased soldier under the National Defense Authorization Act (NDAA).

General Instructions

USCIS provides forms free of charge through the USCIS website. In order to view, print, or fill out our forms, you should
use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/.
Signature. Each declaration must be properly signed and filed. For all signatures on this declaration, USCIS will not
accept a stamped or typewritten name in place of a signature. If you are under 14 years of age, your parent or legal
guardian may sign the declaration on your behalf. A legal guardian may also sign for a mentally incompetent individual.
Validity of Signatures. USCIS will consider a photocopied, faxed, or scanned copy of the original, handwritten signature
valid for filing purposes. The photocopy, fax, or scan must be of the original document containing the handwritten, ink
signature.
Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the What
Evidence Must You Submit and Specific Instructions sections of these Instructions. If you will be submitting the same
documentation (such as tax return transcripts or birth certifications) for the I-485 or the I-864, you do not need to submit
the documentation multiple times.
Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that
you must submit an original document. USCIS may request an original document at the time of filing or at any time
during processing of an application, petition, or declaration. If USCIS requests an original document from you, it will be
returned to you after USCIS determines it no longer needs your original.
NOTE: If you submit original documents when not required or requested by USCIS or the Immigration Court, your
original documents may be immediately destroyed after we receive them.
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Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and that
he or she is competent to translate from the foreign language into English. The certification must include the translator’s
signature. DHS recommends the certification contain the translator’s printed name, the signature date, and the translator’s
contact information.
How To Fill Out Form I-944
1. Type or print legibly in black ink.
2. If you need extra space to complete any item within this declaration, use the space provided in Part 9. Additional
Information or attach a separate sheet of paper. Type or print your name and Alien Registration Number (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.

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3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been
married and the question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many
children do you have” or “How many times have you departed the United States”), type or print “None” unless
otherwise directed.

Specific Instructions

Part 1. Information About You

Item Number 1. Your Current Legal Name. Provide your legal name, as shown on your birth certificate or legal name
change document. If you have two last names, include both and use a hyphen (-) between the names, if appropriate. Type
or print your last, first, and middle names in each appropriate field.
Item Number 2. U.S. Mailing Address. Provide a valid U.S. mailing address.

Item Number 3. Alien Registration Number (A-Number) (if any). An Alien Registration Number, otherwise known
as an “A-Number,” is typically issued to people who apply for, or are granted, certain immigration benefits. In addition
to USCIS, Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), Executive Office
of Immigration Review (EOIR), and the Department of State (DOS) may also issue an A-Number to certain foreign
nationals. If you were issued an A-Number, type or print it in the spaces provided. If you have more than one A-Number,
use the space provided in Part 9. Additional Information to provide the information. If you do not have an A-Number
or if you cannot remember it, leave this space blank.
Item Number 4. USCIS Online Account Number (if any). If you have previously filed an application or petition using
the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)), provide the
USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account Number by
logging in to your account and going to the profile page. If you previously filed certain applications or petitions on a
paper form through a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice issuing
you a USCIS Online Account Number. You may find your USCIS Online Account Number at the top of the notice. If you
were issued a USCIS Online Account Number, enter it in the space provided. The USCIS Online Account Number is not
the same as an A-Number.
Item Number 5. Date of Birth. Enter your date of birth in mm/dd/yyyy format in the space provided. For example, type
or print October 5, 1967 as 10/05/1967.

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Item Number 6. Place of Birth. Enter the name of the city or town, and country where you were born. Type or print
the name of the country as it was named when you were born, even if the country’s name has changed or the country no
longer exists.
Item Number 7. Country of Citizenship or Nationality. Enter the name of the country where you are a citizen. This
is not necessarily the country where you were born. If you are stateless, type or print the name of the country where you
were last a citizen or national. If you are a citizen or national of more than one country, type or print the name of the
foreign country that issued your last passport.
Part 2. Family Status (Your Household)

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USCIS will review your family status as a factor in the public charge inadmissibility determination, which includes an
assessment of your household, as defined in 8 CFR 212.21(d). The term child includes stepchildren and adopted children,
as provided in INA section 101(b)(1).
Item Number 1. Household. The following individuals are part of your household:

1. If you are 21 years of age or older, or under the age of 21 and married, list the following household members in
Part 2., as applicable:
A. You;

B. Your spouse, if physically residing with you;

C. Your children (under the age of 21 and unmarried) physically residing with you;

D. Your other children (under the age of 21 and unmarried) not physically residing with you for whom you provide
or are required to provide at least 50 percent of financial support, as evidenced by a child support order or
agreement, a custody order or agreement, or any other order or agreement specifying the amount of financial
support to be provided by you;
E. Any other individuals (including a spouse not physically residing with you) to whom you provide, or are required
to provide, at least 50 percent of the individual’s financial support, or who are listed as a dependent on your
federal income tax return; and
F. Any individual who provides to you at least 50 percent of your financial support, or who lists you as a dependent
on his or her federal income tax return.
2. If you are a child (under the age of 21 and unmarried) list the following household members on the table in Part 2., as
applicable:
A. You;
B. Your children (under the age of 21 and unmarried) physically residing with you;
C. Your other children (under the age of 21 and unmarried), not physically residing with you for whom you provide
or are required to provide at least 50 percent of financial support, as evidenced by a child support order or
agreement, a custody order or agreement, or any other order or agreement specifying the amount of financial
support to be provided by you;
D. Your parents, legal guardians, or any other individual providing or required to provide at least 50 percent of
financial support to you as evidenced by a child support order or agreement, a custody order or agreement, or any
other order or agreement specifying the amount of financial support to be provided by you;
E. Your parents’ or legal guardians’ other children (under the age of 21 and unmarried) physically residing with you;
F. Your parents’ or legal guardians’ other children (under the age of 21 and unmarried) not physically residing
with you for whom the parent or legal guardian provides or is required to provide at least 50 percent of financial
support, as evidenced by a child support order or agreement, a custody order or agreement, or any other order or
agreement specifying the amount of financial support to be provided by the parents or legal guardians; and

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G. Any other individual to whom your parents or legal guardians provide or other individuals provide, or are required
to provide, at least 50 percent of financial support or who are listed as a dependent on your parents’ or legal
guardians’ federal income tax return.
In addition to listing each household member’s name (including yourself), also provide each individual’s date of birth,
relationship to you (for yourself, you must list “self”), A-Number (if any), and whether the individual is filing an
immigration benefit application with you. If the individual is not filing an immigration benefit application with you,
select “No” when asked “Is this individual filing an application for an immigration benefit with you or has this individual
already filed an application?”
You will have at least one individual listed because you must include yourself.

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Part 3. Your and Your Household Members’ Assets, Resources, and Financial Status

Your assets, resources, and financial status are factors USCIS considers when deciding whether you are inadmissible
based on the public charge ground.
Household Income

Item Number 1. Household Income. List your and your household members’ annual gross (total) income from the most
recent federal income tax returns, if any.
We will consider your household annual gross income, which includes your annual gross income, and any additional
annual gross income from your household members listed in Part 2.
Your household’s annual gross income should be at least 125 percent (100 percent if you are on active duty, other than
in training, in the U.S. Armed Forces) of the Federal Poverty Guidelines for the most recent year as set by the U.S.
Department of Health and Human Services (HHS) for the household size you listed in Part 2. See
https://aspe.hhs.gov/poverty-guidelines.
If your household annual gross income is less than 125 percent of the Federal Poverty Guidelines based on your household
size listed in Part 2., you may demonstrate that the total value of your household’s assets and resources is five times the
difference between your household’s annual gross income and 125 percent (100 percent if you are on active duty, other
than in training, in the U.S. Armed Forces) of the Federal Poverty Guideline for your household size. However, if you are:
1. The spouse or child (who has reached the age of 18) of a U.S. citizen: You have to show that the value of your assets
is at least three times the difference between your household’s annual gross income and 125 percent (100 percent if
you are on active duty, other than in training, in the U.S. Armed Forces) of the Federal Poverty Guidelines for your
household size.
2. An orphan who will be adopted in the United States after you acquire permanent residence (or your parents will seek
a formal recognition of the adoption abroad) and you will acquire citizenship under INA 320: You have to show that
the value of your assets exceeds the difference between your household’s annual gross income and 125 percent (100
percent if you are on active duty, other than in training, in the U.S. Armed Forces) of the Federal Poverty Guideline
for your household size.
Provide the information regarding assets and resources in Item Number 9.
You must provide an IRS transcript(s) of your Federal income tax returns for the most recent tax year and the IRS
transcript(s) of the household members whose income you are including. For information on obtaining federal income
tax transcripts without a fee, see https://www.irs.gov/individuals/get-transcript. You may also use IRS Form 4506-T
to request tax transcripts from the IRS. You are not required to have the IRS certify the transcript or photocopy unless we
specifically instruct you to do so; a plain transcript is acceptable.

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If you are filing Form I-944 between January 1 and April 15 of any year, and you and/or your household members have
not yet filed the current year’s federal income tax return, submit IRS transcripts for the most recent tax year. At the time
of interview on your application, an officer may request the tax return transcripts for the current tax year. Submit any tax
transcripts for any income taxes that you or your household members filed with any foreign government if you or your
household members were residing outside of the United States during any time within the most recent tax year and you
were not required to file a federal individual income tax return with the United States government.
If you are a child (under the age of 21 and unmarried) and are listed as a dependent on your parents’ income tax return, or
if you are listed as a dependent on anyone else’s income tax return, list the total income from that individual’s tax returns
and submit that individual’s IRS tax transcripts for the most recent federal tax year in accordance with the instructions
above.

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If you were not required to file a federal income tax return in any of the prior three tax years, you may provide Form W-2
or a Social Security Statement providing a history of total annual income (gross income). If you provide a W-2 or Social
Security Statement provide the listed wages, tips, or other compensation.
If you need extra space to complete this section, use the space provided in Part 9. Additional Information.
Item Number 6. Additional Income. If you or your household members received additional income on a continuing
weekly, monthly or annual basis for the most recent tax year (for example, child support, unemployment benefits) and the
income was NOT included in your or your household member’s tax return transcript, provide the amount of additional
income and all information requested. For information on non-taxable income see https://www.irs.gov/pub/irs-pdf/
p525.pdf. Also, provide evidence of the additional income from any source in the United States or outside the United
States in U.S. dollars.
Do not list income from any public benefits, as defined in 8 CFR 212.21(b) that you or your household members received
as it is not counted towards income. Do not list any income listed in Item Number 1., Household Income.
Item Numbers 7. and 8. Identify whether any of the additional income comes from an illegal activity or source such as
proceeds from illegal gambling or illegal drug sales or other activities and identify the amount.
Your Household’s Assets and Resources

Item Number 9. Assets. List only the assets that can be converted into cash within 12 months. Provide the value of any
asset held in the United States or outside the United States, in U.S. dollars.
If you or a household member owns a home, you may include the net value of your or the household member’s home as
an asset. The net value of the home is the appraised value of the home, minus the sum of all loans secured by a mortgage,
trust deed, or other lien on the home. If you wish to include the net value of your or your household member’s home,
then you must include documentation demonstrating that you or the household member owns it, a recent appraisal by a
licensed appraiser, and evidence of the amount of all loans secured by a mortgage, trust deed, or other lien on the home.
You may not include the net value of an automobile unless you or your household member shows that you or your
household member have/has more than one automobile, and at least one automobile is not included as an asset.
If you list assets or resources, submit evidence of the value of your or your household member(s)’s assets. You must
include the name of the asset holder, a description of the asset, proof of ownership, and the basis for the owner’s claim of
its net cash value. Evidence of assets and resources include:
1. Checking and savings account statements;
2. Annuities;
3. Stocks and bonds (cash value)/certificates of deposit;
4. Retirement accounts and educational accounts;
5. Net cash value of real estate holdings; and
6. Any other evidence of substantial assets that can be easily converted into cash.
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If you need extra space to complete this section, use the space provided in Part 9. Additional Information.
For checking and savings accounts, you must provide account statements from the bank(s) covering at least 12 months
prior to filing the application. You can also provide any documentation from the household members’ assets. For
additional information, see www.uscis.gov/greencard/public-charge.
Liabilities/Debts
Item Number 10. Liabilities/Debts. Provide a list of all your liabilities or debts. Examples of liabilities and debts
include mortgages, car loans, unpaid child or spousal support, unpaid taxes, and credit card debt. Provide documentation
for each liability or debt. If you need extra space to complete this section, use the space provided in Part 9. Additional
Information.

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Credit Report and Score

Item Numbers 11. - 12. Credit Card Score and Report. USCIS will review your U.S. credit report and the credit score
submitted with your declaration, if available, to review your financial status. If it is available, identify the latest credit
score number.
You can obtain a free credit report once a year under the Fair Credit Reporting Act from each one of the three credit
reporting agencies. You are only required to provide one credit report from any of the three nationwide credit reporting
agencies, Equifax, Experian, and TransUnion. See https://www.usa.gov/credit-reports for more information. If there
are any errors in the credit report, you should provide evidence from the credit reporting agency that demonstrates that
you reported the error and that the error is under investigation or has been resolved.
If you have any negative history in your credit report, you may provide an explanation in the designated area of this
form. Negative credit history may include delinquent accounts, debt collections, charge-offs (delinquent accounts deemed
unlikely to be collected), repossession, foreclosure, judgments, tax liens, or bankruptcy on your credit report.
If you do not have a credit report or credit score, provide documentation that demonstrates that you do not have a credit
report or score with a credit bureau. You may provide evidence of continued payment of bills if there is no credit report or
credit score.
Item Number 14. Bankruptcy. Indicate whether or not you have ever filed for bankruptcy. If you answered “Yes,” list
all the times you filed for bankruptcy, including the type (if filed in the United States), place of filing and the date of the
bankruptcy. Provide evidence of the resolution of each bankruptcy, if available.
Health Insurance
Item Number 15. Health Insurance. If you currently have health insurance, provide the following:
1. For each policy, a copy of each policy page showing the terms and type of coverage and individuals covered; or
2. Letter on the company letter head or other evidence from your health insurance company stating you are currently
enrolled in health insurance and providing the terms and type of coverage; or
3. The latest Form 1095-B, Health Coverage; Form 1095-C, Employer-Provided Health Insurance Offer and Coverage
(if available) with evidence of renewal of coverage for the current year.
A health insurance card is insufficient without effective and expiration dates. If you answered “No,” to Item Number 15.
proceed to Item D.
Item A. Indicate whether or not you have received a Premium Tax Credit or Advanced Premium Tax Credit Tax
Credit for your health insurance. Provide a transcript copy of the IRS Form 8963 Report of Health Insurance Provider
Information, Form 8962 Premium Tax Credit (PTC), and a copy of Form 1095A, Health Insurance Marketplace
Statement.
Item B. Provide the annual amount of deductible or annual premium of your health insurance. Provide documentation of
the amount of deductible or premium.
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Item C. Indicate the date when your insurance terminates or when it must be renewed and provide documentation.
Item D. Indicate whether you have enrolled or soon will enroll in health insurance but your insurance coverage has not
started yet. If you answer “Yes,” provide a letter or other evidence from the insurance company showing that you have
enrolled in or have a future enrollment date for a health insurance plan. The letter or other evidence must include the
terms, the type of coverage, that you are the individual covered, and the date when the coverage begins.
If you answered “No,” you may provide information on how you plan to pay for reasonably anticipated medical costs.
If you have federally funded Medicaid for health insurance, please include the benefit in Item Numbers 15. and 16.
USCIS reviews Form I-693, Report of Medical Examination and Vaccination Record, or Form DS-2053, Medical
Examination for Immigrant or Refugee Applicant, to determine whether you have a medical condition that will affect your
ability to work, attend school, or care for yourself.

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You may provide any documentation that may outweigh any negative factors related to a medical condition, including
but not limited to, information provided by a civil surgeon or a panel physician on a medical examination. You may also
provide an attestation from your treating physician regarding the prognosis of any medical condition and whether this
medical condition impacts your ability to work or go to school. You may also provide evidence of sufficient assets and
resources to pay the costs of any reasonably anticipated medical treatment.
Public Benefits

Item Number 16. Application, Receipt or Certification of Public Benefits.

Please provide the information requested about your (the alien’s) application or certification for, or receipt of, public
benefits. Please provide all requested information about each public benefit regardless of amount or duration, as USCIS
will calculate the duration of the public benefit. If you received public benefits intermittently throughout the year, provide
each instance separately. For example, if you received SNAP from January to February and June to December, provide
the information as two separate instances. If you require additional space, please use the space provided in Part 9.
Additional Information.
Receipt means when a benefit-granting agency provides or has provided a public benefit to you whether in the form of
cash, voucher, services, or insurance coverage. USCIS will only consider the amount received by or attributable to the
alien.
In the space provided, indicate whether you have ever received, currently receive, or are currently certified to receive any
of the following public benefits. (You must respond even if you fall within one of categories of individuals for whom
receipt of public benefits will not be considered – see the table below for evidence that must be provided to document that
you qualify for the exclusion). Please select all that apply.
1. Any Federal, State, local, or tribal cash assistance for income maintenance;
2. Supplemental Security Income (SSI);
3. Temporary Assistance for Needy Families (TANF);
4. Federal, State or local cash benefit programs for income maintenance (often called “General Assistance” in the State
context, but which may exist under other names);
5. Supplemental Nutrition Assistance Program (SNAP, or formerly called “Food Stamps”);
6. Section 8 Housing Assistance under the Housing Choice Voucher Program;
7. Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation);
8. Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.; and
9. Federally funded Medicaid.

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NOTE: For benefits received before October 15, 2019, you only need to report receipt of SSI, cash, TANF, General
Assistance, and benefits received for long-term institutionalization. You do not need to report receipt of SNAP, Medicaid
(other than Medicaid benefits used to fund long-term institutionalization), Section 8 Housing Assistance under the
Housing Choice Voucher Program, Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation),
and Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq. if received before October 15, 2019. These
benefits were excluded from consideration for public charge inadmissibility purposes under the guidance in place before
October 15, 2019, and therefore will not be considered if received only before October 15, 2019.
If you have not received any public benefits, please select that option.
If you are not currently certified to receive any public benefits, please select that option.

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In the space provided, indicate whether you have ever applied for a public benefit listed above but your application was
denied or rejected; provide documentation of the denial or rejection.
As part of the public charge inadmissibility determination under INA section 212(a)(4), we will generally consider any
past, current receipt, or certification of future receipt of public benefits.
NOTE: To the extent that States give the same name to their Federal Medicaid program and the state-only funded health
insurance program, aliens will not be required to report the receipt of the state-only funded health insurance.

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The following is a list of exclusions from the public benefit receipt consideration listed above. If you belong to one of the
following categories, submit the evidence listed for the applicable categories.
Exclusion

Description

Evidence you must submit to qualify for
exclusion (as applicable)

U.S. Armed
Forces Service
Members

At the time the public benefit was received at
the time you file your Form I-485, or at time of
adjudication of your Form I-485, you are:

•

•

•

Federally-funded
Medicaid

•
•
•

•

•

An alien enlisted in the U.S. Armed Forces,
or serving in active duty or in the Ready
Reserve component of the U.S. Armed
•
Forces; or

Service Members: Certified evidence
of alien’s enlistment/service issued by
the authorizing official of the executive
department in which service member is
serving.

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The spouse or child of an individual
enlisted in the U.S. Armed Forces, or
serving in active duty or in the Ready
Reserve component of the U.S. Armed
Forces.

Receipt by an alien under 21 years of age;
The recipient of Medicaid payment(s) for
an “emergency medical condition”;
The receipt of Medicaid for services
provided under the Individuals with
Disabilities Education Act (IDEA);

The receipt of Medicaid for school-based
non-emergency benefits for children
who are of an age eligible for secondary
education as determined under state law; or

Spouses and Children of Service Members:
Form DD-1173, United States Uniformed
Services Identification and Privilege Card
(Dependent).

•

A statement with information regarding
the “emergency medical condition”
determination (if applicable);

•

Documentation of these payments under the
IDEA or school-based service; or

•

Pregnancy verification letter from medical
professional including estimated duration of
pregnancy.

Receipt during pregnancy and during the
60-day period after the last day of the
pregnancy.

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Exclusion

Description

Evidence you must submit to qualify for
exclusion (as applicable)

Children
Acquiring U.S.
Citizenship

•

•

•

Public Benefits
While in an
Immigration
Category
Exempt from
Public Charge

Documentation

•

•

Child of U.S. citizens whose lawful admission
for permanent residence and subsequent
residence in the legal and physical custody
of their U.S. citizen parent will result in
the child’s automatically acquiring U.S.
citizenship upon meeting the eligibility under
INA 320; or

Evidence that you are the child of a
United States citizen, who will be eligible
for acquisition of citizenship under INA
320 and the evidentiary requirements to
meet the qualifications to demonstrate
citizenship. For more information, see
Form N-600, Application for Certificate of
Citizenship.

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Child of U.S. citizens whose lawful
admission for permanent residence will result
automatically in the child’s acquisition of
citizenship upon finalization of adoption (if
the child satisfies the requirements applicable
to adopted children under INA 101(b)(1)), in
the United States by the U.S. citizen parent(s),
upon meeting the eligibility criteria under INA
320.
Received public benefits while in a
category that is exempt from public charge
inadmissibility; or

•

Received public benefits while in a category
for which you received a waiver for public
charge inadmissibility.

Information that evidences your status or
that you received a waiver for the public
charge ground of inadmissibility, such as:
•

Approval notice (such as Form I-797,
Notice of Action); or

•

Form I-94, Arrival/Departure Record.

If you have applied for, are currently receiving, previously received, or are certified to receive in the future any of the
public benefits listed above, provide evidence in the form of a letter, notice, certification, or other agency document that
contains the following:
1. Your name;
2. Name and contact information for the public benefit-granting agency;
3. Type of public benefit;
4. Date you were authorized to start receiving the benefit or date your coverage starts; and
5. Date benefit or coverage ended or expires (mm/dd/yyyy) (if applicable).
If you have applied for, are currently receiving, previously received or are certified to receive public benefits but an
exclusion applies, please indicate whether an exclusion applies to you in Item Number 19. and provide the evidence
listed in the chart above to demonstrate why the benefit should not be considered.
Item Number 17. Disenrollment from Public Benefits. If you answer “Yes” to Item Number 17., please provide
evidence of your disenrollment or your request to disenroll if the public benefit granting agency has not processed your
request.
Item Number 25. Withdrawing a Public Benefit Application. If you had applied for a public benefit but withdrew
your application, provide evidence demonstrating that the public benefit granting agency received your request to
withdraw the application.
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You may also submit evidence from a federal, state, local, or tribal agency administering a public benefit that shows that
you do not qualify or would not qualify for such public benefit by virtue of, for instance, your annual gross household
income or your prospective immigration status.
Item Number 26. Applications for or Receipt of Immigration Fee Waivers. Indicate whether or not you have ever
applied for or received a fee waiver when applying for an immigration benefit. If you answered “Yes,” list when you
received the fee waiver, the type of immigration benefit for which you applied, and the receipt number for the application
or petition for which the fee was waived.
If you need extra space to complete this section, use the space provided in Part 9. Additional Information. You may
also use this section to explain the circumstances that caused you to apply for a fee waiver and if those circumstances have
changed. If those circumstances have changed, please provide any documents you may have to support your explanations.

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Part 4. Your Education and Skills

USCIS will review employment and unemployment information you provide on your Form I-485. Please see the
Form I-485 and Instructions for additional information. If you are currently unemployed because you are the primary
caretaker of a child or elderly or disabled individual, which has limited your ability to work, provide a statement in Part
9. Additional Information. In addition, provide any documentation establishing you are the primary caretaker (for
example legal guardianship court order), that an individual resides in your household, and the individual’s age and/or the
individual’s medical condition (if applicable).
Item Number 1. Form I-140 Approval. Indicate whether you have an approved Form I-140. If you answered “Yes,”
skip this Part and proceed to Part 5. If you answered “No,” proceed to Item Number 2.
Item Numbers 2. and 3. Indicate whether or not you have graduated high school or earned an equivalent of a high school
diploma or whether you have a higher degree. If you did not graduate high school, list the highest grade completed.
Also, list all educational programs you attended in the space provided, such as high school, college, or other higher
education. Provide the name of the program or school, the degree or certificate received, if any, the field of study, and the
start and end dates. Enter your degree program start date and end date in mm/dd/yyyy format. If your degree program
does not start and end on a specific day (i.e. “dd”), provide your best estimate of the day. If it is available, you must
provide evidence of any degrees or certifications received, such as transcripts, diplomas, degrees, and trade profession
certificates or equivalent (if this evidence is unavailable, you should provide an explanation and, if possible, evidence of
unavailability such as a letter from the issuing institution). Foreign education should include an evaluation of equivalency
to education or degrees acquired at accredited colleges, universities, or educational institutions in the United States. For
a list of organizations that provide equivalency evaluation, see the National Association of Credential Evaluation Services
(NACES), at http://www.naces.org/members.htm.
Item Number 4. Occupational Skills. List any relevant occupational skills, including any certifications and licenses,
when these were obtained, who issued the certification or license, license numbers, and expiration/renewal date. This
includes but is not limited to workforce skills, training, licenses for specific occupations or professions, and certificates
documenting mastery or apprenticeships in skilled trades or professions. If it is available, you must provide evidence of
any training, licenses for specific occupations or professions, and certificates documenting mastery or apprenticeships in
skilled trades or professions (if this evidence is unavailable, you should provide an explanation and, if possible, evidence
of unavailability such as a letter from the issuing institution).
Item Number 5. English and Other Language Skills. Provide information on certifications or courses in English and
other languages in addition to English. Provide any evidence of language certifications, including any language or literacy
classes you took or are currently taking, or other evidence of proficiency. Native English speakers, or other language if
applicable, must provide documentation of language proficiency including language certifications. Evidence of language
certification may include high school diplomas and college degrees showing that the native language was studied for
credit.

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Item Number 6. Retirement. Indicate whether or not you are retired and provide the date of retirement, if applicable.
If you have not already provided the information in Part 3. Item Number 9., provide evidence of income from pensions,
social security or other retirement benefits.
Part 5. Declarant’s Statement, Contact Information, Certification, and Signature
Item Numbers 1. - 6. Select the appropriate box to indicate whether you read this declaration yourself or whether you
had an interpreter assist you. If someone assisted you in completing the declaration, select the box indicating that you
used a preparer. Further, you must sign and date your declaration and provide your daytime telephone number, mobile
telephone number (if any), and email address (if any). Every declaration MUST contain the signature of the declarant (or
parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

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Part 6. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1. - 7. If you used anyone as an interpreter to read the Instructions and questions on this declaration to
you in a language in which you are fluent, the interpreter must fill out this section; provide his or her name, the name and
address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone
number (if any), and his or her email address (if any). The interpreter must sign and date the declaration.
Part 7. Contact Information, Declaration, and Signature of the Individual Preparing this Declaration, if Other
Than the Declarant
Item Numbers 1. - 8. This section must contain the signature of the individual who completed your declaration, if other
than you, the declarant. If the same individual acted as your interpreter and your preparer, that person should complete
both Part 6. and Part 7. If the individual who completed this declaration is associated with a business or organization,
that person should complete the business or organization name and address information. Anyone who helped you
complete this declaration MUST sign and date the declaration. A stamped or typewritten name in place of a signature
is not acceptable. If the individual who helped you prepare your declaration is an attorney or accredited representative,
he or she may also need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, along with your declaration.
Part 8. Signature at Interview

Do not complete this part. The USCIS Officer will ask you to complete this part at your interview.
Part 9. Additional Information

Item Numbers 1. - 6. If you need extra space to provide any additional information within this declaration, use the space
provided in Part 9. Additional Information. If you need more space than what is provided in Part 9., you may make
copies of Part 9. to complete and file with your declaration 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.

We recommend that you print or save a copy of your completed declaration to review in the
future and for your records.

What Evidence Must You Submit?
You must submit all initial evidence requested in these Instructions with your Form I-944. If you fail to submit required
evidence, your application may be rejected or denied in accordance with 8 CFR 103.2(a) and (b)(1) and these Instructions.

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What Is the Filing Fee?
There is currently no filing fee for Form I-944.

Filing Form I-944 With Form I-485
Submit Form I-944 at the same time you submit Form I-485.

Where To File?

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Please see our website at www.uscis.gov/I-944 or visit the USCIS Contact Center at www.uscis.gov/contactcenter to
connect with a USCIS representative for the most current information about where to file this declaration.
If you are in proceedings in Immigration Court (that is, if you have been served with Form I-221, Order to Show Cause
and Notice of Hearing; Form I-122, Notice to Applicant for Admission Detained for Hearing Before an Immigration
Judge; Form I-862, Notice to Appear; or Form I-863, Notice of Referral to Immigration Judge, that DHS filed with the
Immigration Court), you should file this declaration with the appropriate Immigration Court.
The DHS attorney will provide you with Pre-Order Filing Instructions regarding background and security investigations.
You must also submit a copy to USCIS. Please see our website at
www.uscis.gov/laws/immigration-benefits-eoir-removal-proceedings or call our National Contact Center for the most
current information about where to file the copy of the application that you file with the Immigration Court.

Address Change

A declarant who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his or
her previous residence. For information on filing a change of address, go to the USCIS website at
www.uscis.gov/addresschange.
If you are already in proceedings in Immigration Court, you must also notify the Immigration Court on EOIR Form 33/IC,
Alien’s Change of Address Form/Immigration Court, of any changes of address within five days of the change in address.
The EOIR Form 33/IC is available on the EOIR website at http://www.justice.gov/eoir/formslist.htm.
NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not
process change of address requests.

Processing Information
You must be physically present in the United States and provide a United States address to file this declaration. Your
declaration will be rejected if it is not signed. You may fix the problem and resubmit Form I-944. Form I-944 is not
considered properly filed until it is accepted.
Initial Processing. Once your declaration is accepted, it will be checked for completeness. If you do not completely fill
out this declaration, you will not establish a basis for your eligibility and your declaration may be rejected or denied.
Requests for More Information. USCIS may request that you provide more information or evidence to support your
declaration. We may also request that you provide the originals of any copies you submit. If we request an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.

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Requests for Interview. We may request that you appear at a USCIS office for an interview based on your declaration.
At the time of any interview or other appearance at a USCIS office, we may require that you provide your biometrics to
verify your identity and/or update background and security checks.
For hearings before the Immigration Court: Interpreters are provided, at the government’s expense, to individuals
whose comprehension of the English language is inadequate to fully understand and participate in removal proceedings.
In general, the Immigration Court endeavors to accommodate the language needs of all respondents and witnesses. The
Immigration Court will arrange for an interpreter both during the individual calendar hearing and, if necessary, the master
calendar hearing. The Immigration Court is also committed to addressing the needs of individuals with disabilities and/or
impairments. If your case is pending before the Immigration Court, you should notify the court of any such need before
your first hearing with an immigration judge. The Immigration Court considers all requests to address such needs on a
case-by-case basis.

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USCIS Forms and Information

To ensure you are using the latest version of this declaration, visit the USCIS website at www.uscis.gov where you can
obtain the latest USCIS forms and immigration-related information.
Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at
www.uscis.gov. Select “Make an Appointment” and follow the screen prompts to set up your appointment. Once you
finish scheduling an appointment, the system will generate an appointment notice for you.

Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-944, we will
deny your Form I-944 and may deny any other immigration benefit. In addition, you will face severe penalties provided
by law and may be subject to criminal prosecution.

USCIS Compliance Review and Monitoring

By signing this declaration, you have stated under penalty of perjury (28 USC section 1746) that all information and
documentation submitted with this declaration are complete, true, and correct. You also authorize the release of any
information from your records that USCIS may need to determine your eligibility for the immigration benefit you are
seeking and consent to USCIS verifying such information.
DHS has the authority to verify any information you submit to establish eligibility for the immigration benefit you are
seeking at any time. USCIS’ legal authority to verify this information is in 8 U.S.C. sections 1103, 1155, and 1184, and
8 CFR Parts 103, 204, 205, and 214. To ensure compliance with applicable laws and authorities, USCIS may verify
information before or after your case is decided.
Agency verification methods may include, but are not limited to: review of public records and information; contact
through written correspondence, the Internet, facsimile, other electronic transmission, or telephone; unannounced physical
site inspections of residences and locations of employment; and interviews. USCIS will use information obtained through
verification to assess your compliance with the laws and to determine your eligibility for an immigration benefit.
Subject to the restrictions under 8 CFR 103.2(b)(16), USCIS will provide you with an opportunity to address any adverse
or derogatory information that may result from a USCIS compliance review, verification, or site visit after a formal
decision is made on your case or after the agency has initiated an adverse action which may result in revocation or
termination of an approval.

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DHS Privacy Notice
AUTHORITIES: The information requested on this declaration, and the associated evidence, is collected under the
Immigration and Nationality Act (INA) section INA 212(a)(4).

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PURPOSE: The primary purpose for providing the requested information on this form is to provide documentation to
demonstrate that you are not likely to become a public charge. DHS uses the information you provide to grant or deny the
immigration benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number (if applicable), and any requested evidence, may delay a final decision or result in
denial of your form.
ROUTINE USES: DHS may share the information you provide on this declaration and any additional requested
evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows
approved routine uses described in the associated published system of records notices [DHS/USCIS-001 - Alien File,
Index, and National File Tracking System and DHS/USCIS-007 - Benefits Information System] and the published
privacy impact assessments [DHS/USCIS/PIA-016a Computer Linked Application Information Management System and
Associated Systems,] which you can find at www.dhs.gov/privacy. DHS may also share this information, as appropriate,
for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and an individual is not required to respond to a
collection of information, unless it displays a currently valid Office of Management and Budget (OMB) control number.
The public reporting burden for this collection of information is estimated at 4.5 hours per response, including the time
for reviewing instructions, gathering the required documentation and information, completing the declaration, preparing
statements, attaching necessary documentation, and submitting the declaration. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S.
Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts
Ave NW, Washington, DC 20529-2140; OMB No. 1615-0142. Do not mail your completed Form I-944 to this address.

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