Form I-864 Affidavit of Support Under Section 213A of the INA

USCIS
Form I-864

Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services
Affidavit of Support Submitter
For
USCIS
Use
Only

Petitioner
1st Joint Sponsor
2nd Joint Sponsor
Substitute Sponsor
5% Owner

OMB No. 1615-0075
Expires 03/31/2020

Adjusted Household Size
Number of Support Affidavits in File
Section 213A Review
2
1
MEETS
DOES NOT MEET Remarks
requirements
requirements
Reviewed By:
Office:
Date (mm/dd/yyyy):

DRAFT
NOT FOR
PRODUCTION
06/22/2020

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.

Part 1. Basis For Filing Affidavit of Support

Mailing Address

,

I,

am the sponsor submitting this affidavit of support because
(Select only one box):
1.a.

I am the petitioner. I filed or am filing for the
immigration of my relative.

1.b.

I filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my

(USPS ZIP Code Lookup)

2.a. In Care Of Name

2.b. Street Number and Name

2.c.

Apt.

Ste.

Flr.

2.d. City or Town

1.c.

I have an ownership interest of at least 5 percent in

2.e. State

2.f.

ZIP Code

2.g. Province

which filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my

2.h. Postal Code
2.i.

1.d.

I am the only joint sponsor.

1.e.

I am the

1.f.

The original petitioner is deceased. I am the
substitute sponsor. I am the intending immigrant's

first

Country

second of two joint sponsors.

Other Information
3.

Country of Citizenship or Nationality

4.

Date of Birth (mm/dd/yyyy)

5.

Gender

Part 2. Information About the Principal
Immigrant

6.

Alien Registration Number (A-Number) (if any)
► A-

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

7.

USCIS Online Account Number (if any)
►

8.

Daytime Telephone Number

NOTE: If you are filing this form as a sponsor, you must
include proof of your U.S. citizenship, U.S. national status,
or lawful permanent resident status.

Male

Female

1.c. Middle Name
Form I-864 03/06/18

Page 1 of 12

Part 2. Information About the Principal
Immigrant (continued)

12.

Alien Registration Number (A-Number) (if any)
► A-

9.

13.

USCIS Online Account Number (if any)
►

Relationship to Sponsor

Part 3. Information About the Immigrants You
Are Sponsoring
1.

2.

3.

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

DRAFT
NOT FOR
PRODUCTION
06/22/2020

I am sponsoring the principal immigrant named in Part 2.
Yes

Family Member 3

No (Applicable only if you are sponsoring
family members in Part 3. as the second
joint sponsor or if you are sponsoring
family members who are immigrating
more than six months after the principal
immigrant)

I am sponsoring the following family members
immigrating at the same time or within six months of
the principal immigrant named in Part 2. (Do not
include any relative listed on a separate visa petition.)

I am sponsoring the following family members who
are immigrating more than six months after the principal
immigrant.

14.c. Middle Name
15.

Relationship to Principal Immigrant

16.

Date of Birth (mm/dd/yyyy)

17.

Alien Registration Number (A-Number) (if any)
► A-

18.

USCIS Online Account Number (if any)
►

Family Member 4

Family Member 1

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

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

19.c. Middle Name

4.c. Middle Name
5.

Relationship to Principal Immigrant

6.

Date of Birth (mm/dd/yyyy)

7.

Alien Registration Number (A-Number) (if any)
► A-

8.

20.

Relationship to Principal Immigrant

21.

Date of Birth (mm/dd/yyyy)

22.

Alien Registration Number (A-Number) (if any)
► A-

23.

USCIS Online Account Number (if any)
►

USCIS Online Account Number (if any)
►

Family Member 5
Family Member 2
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
10.

Relationship to Principal Immigrant

11.

Date of Birth (mm/dd/yyyy)

Form I-864 03/06/18

24.a. Family Name
(Last Name)
24.b. Given Name
(First Name)
24.c. Middle Name
25.

Relationship to Principal Immigrant

26.

Date of Birth (mm/dd/yyyy)

Page 2 of 12

Part 3. Information About the Immigrants You
Are Sponsoring (continued)
27.

Alien Registration Number (A-Number) (if any)
► A-

28.

USCIS Online Account Number (if any)
►

29.

Sponsor's Physical Address
4.a. Street Number and Name

4.b.

Apt.

Ste.

Flr.

4.c. City or Town

DRAFT
NOT FOR
PRODUCTION
06/22/2020

Enter the total number of immigrants you are sponsoring
on this affidavit which includes the principal immigrant
listed in Part 2., any immigrants listed in Part 3., Item
Numbers 1. - 28. and (if applicable), any immigrants
listed for these questions in Part 12. Additional
Information. Do not count the principal immigrant if you
are only sponsoring family members entering more than 6
months after the principal immigrant.
►

Part 4. Information About You (Sponsor)

4.d. State

4.f.

4.e. ZIP Code

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

2.a. In Care Of Name

9.

Country of Birth

2.b. Street Number and Name

10.

U.S. Social Security Number (Required)

Sponsor's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name

Sponsor's Mailing Address

►

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

Citizenship or Residency
11.a.

I am a U.S. citizen.

11.b.

I am a U.S. national.

11.c.

I am a lawful permanent resident.

12.

Sponsor's A-Number (if any)
► A-

13.

Sponsor's USCIS Online Account Number (if any)
►

Military Service (To be completed by petitioner sponsors only.)
14.

I am currently on active duty in the U.S. Armed Forces,
Yes
No
other than for active duty training.

If you answered "No" to Item Number 3., provide your
physical address in Item Numbers 4.a. - 4.h.

Form I-864 03/06/18

Page 3 of 12

Part 4. Information About You (Sponsor)
(continued)

6.

If you have sponsored any other persons on Form I-864 or
Form I-864EZ who are now lawful permanent residents
and for whom your support obligation has not ended,
enter the number here.
►

7.

Optional: If you have siblings, parents, or adult children
with the same principal residence who are combining
their income with yours by submitting Form I-864A, enter
the total number of people here:
►

Sponsor's Bank Account Information
15.a. Account Type
Checking

Savings

15.b. Account Holder's Name

DRAFT
NOT FOR
PRODUCTION
06/22/2020

Family Name
(Last Name)
Given Name
(First Name)

8.

Add together Part 5., Item Numbers 1. - 7. and enter the
number here
Household Size: ►

Middle Name

15.c. Name(s) of Joint Account Holders, if any

Part 6. Previously Submitted Affidavits of
Support

Family Name
(Last Name)
Given Name
(First Name)

1.

Have you submitted Form I-864 or Form I-864EZ for any
individuals other than those named on this form?

Middle Name

15.d. Institution Name

15.e. Account Number

15.f. Routing Number

Part 5. Sponsor's Household Size

NOTE: Do not count any member of your household more
than once.
Individuals you are sponsoring in this affidavit:
1.

Provide the number you entered in Part 3., Item Number
29.
►

Individuals NOT sponsored in this affidavit:

No

2.

If you answered “Yes” to Item Number 1., enter the total
number of individuals for whom you previously submitted
Form I-864 or Form I-864EZ.
►

3.

Provide the following information about each individual
for whom you previously submitted Form I-864 or Form
I-864EZ. If you need more space to provide the
information, use Part 12. Additional Information. You
do not need to include any individual for whom your
sponsorship obligation has ended, that is, if you know
that: 1) the individual became a United States citizen, 2)
the individual is currently a lawful permanent resident
that has worked or can be credited with 40 qualifying
quarters of coverage, 3) the individual abandoned or lost
his or her lawful permanent resident status, 4) the
individual is deceased, or 5) the individual is obtaining a
new grant of adjustment of status while in removal
proceedings based on a new affidavit of support, if one is
required.
a.

Sponsored Individual's Name

b.

Date of Birth (mm/dd/yyyy)

c.

Alien Registration Number

►

2.

Yourself.

3.

If you are currently married, enter "1" for your spouse.
►

4.

If you have dependent children, enter the total number of
dependent children here.
►

5.

If you have any other dependents, enter the total number
of other dependents here.
►

Form I-864 03/06/18

Yes

► A-

Page 4 of 12

Household Size
2
1
3
4
5
6
7
8
9
Other

For
USCIS
Use
Only

Poverty Guideline

Remarks

Year: 2 0
Poverty Line:
$

Part 7. Sponsor's Employment and Income

DRAFT
NOT FOR
PRODUCTION
06/22/2020

I am currently:
1.
Employed as a/an

2.

3.

Person 3
14.

Name

15.

Relationship

16.

Current Income

Name of Employer 1

Name of Employer 2 (if applicable)

4.

Person 4
17.

Name

18.

Relationship

19.

Current Income

20.

My Current Annual Household Income (Total all lines
from Part 7. Item Numbers 7., 10., 13., 16., and 19.; the
total will be compared to Federal Poverty Guidelines on
Form I-864P.)
$

Self-Employed as a/an (Occupation)

5.

Retired Since (mm/dd/yyyy)

6.

Unemployed Since (mm/dd/yyyy)

7.

My current individual annual income is:
$

Income you are using from any other individual who was
counted in your household size, including, in certain conditions,
the intending immigrant. (See Form I-864 Instructions.) Please
indicate name, relationship, and income.
Person 1
8.

Name

9.

Relationship

10.

Current Income

12.

21.

The people listed in Item Numbers 8., 11., 14., and
17. have completed Form I-864A. I am filing along
with this affidavit all necessary Form I-864As
completed by these people.

22.

One or more of the people listed in Item Numbers
8., 11., 14., and 17. do not need to complete Form
I-864A because he or she is the intending immigrant
and has no accompanying dependents.

$

Federal Income Tax Return Information
23.a. Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No

Name

NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
tax year.

Relationship
23.b.

13.

Current Income

$

Name

Person 2
11.

$

$

(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 as reported on my Federal income tax returns
for the most recent three years was:

Form I-864 03/06/18

Page 5 of 12

For
USCIS
Use
Only

Household Size
2
1
3
4
5
6
7
8
9
Other

Poverty Guideline

Remarks

Year: 2 0
Poverty Line:
$

Part 7. Sponsor's Employment and Income
(continued)

DRAFT
NOT FOR
PRODUCTION
06/22/2020
Tax Year

Total Income

24.a. Most Recent

$

24.b. 2nd Most Recent

$

24.c. 3rd Most Recent

$

25.

5.b. Your household member's total assets from Form I-864A,
Part 4., Item Number 4.
$

I was not required to file a Federal income tax return
as my income was below the IRS required level and I
have attached evidence to support this.

Assets of the principal sponsored immigrant (Optional)

The principal sponsored immigrant is the individual listed in
Part 2., Item Numbers 1.a. - 1.c. Only include the assets if the
principal immigrant is being sponsored by this affidavit of
support.
6.

Enter the balance of the principal immigrant's savings and
checking accounts.
$

7.

Enter the net cash value of all the principal immigrant's
real estate holdings. (Net value means investment value
minus mortgage debt.)
$

8.

Enter the current cash value of the principal immigrant's
stocks, bonds, certificates of deposit, and other assets not
included in Item Number 6. or Item Number 7.

Credit Report Information (Optional)
26.

I have attached a copy of a recent credit report.

Part 8. Use of Assets to Supplement Income
(Optional)

If your income, or the total income for you and your household,
from Part 7., Item Numbers 20. or 24.a. - 24.c., exceeds the
Federal Poverty Guidelines for your household size, YOU ARE
NOT REQUIRED to complete this Part 8. Skip to Part 9.

9.

Add together Item Numbers 6. - 8. and enter the number
here.
$

Total Value of Assets

Your Assets (Optional)
1.

$

Enter the balance of all savings and checking accounts.

10.

Add together Item Numbers 4., 5.b., and 9. and enter the
number here.

$

2.

Enter the net cash value of real-estate holdings. (Net
value means current assessed value minus mortgage debt.)
$

3.

Enter the net cash value of all stocks, bonds, certificates
of deposit, and any other assets not already included in
Item Number 1. or Item Number 2.
$

4.

Add together Item Numbers 1. - 3. and enter the number
here.
TOTAL: $

Assets from Form I-864A (Optional) If you need to provide
information about more than one Form I-864A, use the space
provided in Part 12. Additional Information.

TOTAL: $

Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-864
Instructions before completing this part.

Sponsor's Contract
Please note that, by signing this Form I-864, 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-864. If
you do not understand the obligations, you may wish to consult
an attorney or accredited representative.

5.a. Name of household member

Form I-864 03/06/18

Page 6 of 12

Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
What is the Legal Effect of My Signing Form I-864?
If you sign Form I-864 on behalf of any individual (called the
intending immigrant) who is applying for an immigrant visa or
for adjustment of status to that of a lawful permanent resident,
and that intending immigrant submits Form I-864 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.

The U.S. Government cannot make you sign Form 1-864 if you
do not want to do so. But if you do not sign Form I-864, the
intending immigrant may not become a lawful permanent
resident in the United States.
What Does Signing Form I-864 Require Me To Do?

If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864 that you have
signed, then you must do all of the following until your
obligations under this Form I-864 terminate:

B.

What If I Do Not Fulfill My Obligations?

DRAFT
NOT FOR
PRODUCTION
06/22/2020

What If I Choose Not to Sign Form I-864?

A.

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 public benefits under the Elementary
and Secondary Education Act.

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 your household size (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 intending
immigrant is your husband, wife, or unmarried child
under 21 years of age); and
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.

If you do not provide sufficient support to the individual who
becomes a lawful permanent resident based on a Form I-864
that you signed, that individual may sue you for this support.
If a Federal, state, local, or private agency provided any covered
means-tested public benefit to the person who becomes a lawful
permanent resident based on this Form I-864 that you signed,
you are responsible for reimbursing the agency 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 fail to reimburse the benefit
granting agency upon request, you may be found ineligible to be
a sponsor in the future.
If you are sued, and the court enters a judgment against you, the
individual 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 this Form I-864 will end if the
individual you are sponsoring who becomes a lawful permanent
resident based on the application for which this affidavit was
required:
A.

Becomes a U.S. citizen;

B.

Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;

C.

Has abandoned or lost lawful permanent resident
status and has departed the United States;

D.

Is 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

E.

Dies.

What Other Consequences Are There?
If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864 that you have signed,
then, until your obligations under Form I-864 terminate, the U.S.
Government may consider (deem) your income and assets as
available to that individual, 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 individual.

Form I-864 03/06/18

Your obligations under this Form I-864 also end if you die.
Therefore, if you die, your estate is not required to take
responsibility for the individual's support after your death.
However, your estate may be required to reimburse a benefit
granting agency for any means-tested public benefits that the
intending immigrant received before you died.

Page 7 of 12

I certify, under penalty of perjury, that:

Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)

A.

I provided or authorized all of the information in my
affidavit, I understand all of the information
contained in, and submitted with, my affidavit, and
that all of this information is complete, true, and
correct;

B.

I am willing and able to receive, maintain, and
provide support to the individual named in Part 3. at
the applicable threshold set forth in the Poverty
Guidelines and by statute;

NOTE: Divorce does not terminate your obligations under
Form I-864.

Sponsor's Statement

DRAFT
NOT FOR
PRODUCTION
06/22/2020

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 I have read
and understand every question and instruction on this
affidavit and my answer to every question.

1.b.

The interpreter named in Part 10. read to me every
question and instruction on this affidavit and my
answer to every question in

C.

I understand that during the duration of my obligation
as a sponsor, I may be sued if the individuals named
in Part 3. receive means-tested benefits after
admission to the United States as immigrants or after
being granted adjustment of status;

D.

I understand that Form I-864 may be made available
to any Federal, State, or local agency that may
receive an application from the individuals named in
Part 3. for Supplemental Nutrition Assistance
Program (SNAP) benefits (formerly called Food
Stamps), Medicaid (other than Emergency Medicaid),
Supplemental Security Income, Temporary
Assistance to Needy Families, or other means-tested
benefits;

E.

I understand that if the individual named in Part 3.
does apply for SNAP/Food Stamps, Supplemental
Security Income, Medicaid (other than Emergency
Medicaid) or Temporary Assistance for Needy
Families or other means-tested benefits, my own
income and assets may be considered in deciding the
individual's application. How long my income and
assets may be attributed to the individual named in
Part 3. is determined under the statutes and rules
governing each specific program;

F.

I have read the section entitled Sponsor and
Beneficiary Liability in the Instructions for this
affidavit, and am aware of my responsibilities as a
sponsor under the Social Security Act, as amended,
and the Food Stamp Act, as amended;

G.

I agree to submit to the personal jurisdiction of any
Federal state, or local court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864;

H.

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.

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-864;

,

a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 11.,

,

prepared this affidavit for me based only upon
information I provided or authorized.

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 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 benefit that I seek.
I furthermore authorize release of information contained in this
affidavit, 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.

Form I-864 03/06/18

Page 8 of 12

Part 9. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
J.

I understand that if I fail to respond within 45 days to
a request for reimbursement from a public benefitgranting agency or an appropriate government entity
because the individual named in Part 3. received a
means-tested benefit, an action may be brought
against me pursuant to the affidavit of support;

K.

I understand that I may be subject to a civil penalty if
I fail to notify U.S. Citizenship and Immigration
Services (USCIS) of any change in my address,
within 30 days of the change, by filing Form I-865,
Sponsor's Notice of Change of Address;

L.

I authorize agencies and entities that administer or
oversee means-tested public benefits, and any agency
or entity that is authorized to act on its behalf, to
disclose information to the Department of Homeland
Security (DHS) and Department of State (DOS), for
the purpose of administration of federal laws
regarding my obligations as a sponsor, as agreed to in
this affidavit and only as permitted by law. If any
alien that I sponsor on this affidavit applies for a
means-tested public benefit, including Medicaid, the
Children's Health Insurance Program, Temporary
Assistance to Needy Families, or the Supplemental
Nutrition Assistance Program, or any other Federal or
State public benefit subject to deeming of my income
and/or assets/resources or for which I could be liable
for reimbursement, I specifically authorize the
agencies and entities that administer or oversee
means-tested public benefits, and any agency or
entity that is authorized to act on its behalf, to
disclose my name, Social Security number, date of
birth, information about the agency's deeming of my
income and/or assets/resources, and any
reimbursement obligations to DHS and DOS. This
consent is valid for the entire period of enforceability
of my obligations as a sponsor.

M.

I authorize the Social Security Administration (SSA)
to disclose information to DHS and DOS, for the
purpose of administration of federal laws regarding
my obligations as a sponsor, as agreed to in this
affidavit and only as permitted by law. If any alien
that I sponsor on this affidavit applies for
Supplemental Security Income payments, I
specifically authorize SSA to disclose my name,
Social Security number, date of birth, the deeming of
my income and/or assets/resources, and my
reimbursement obligations to DHS and DOS. This
consent is valid for the entire period of enforceability
of my obligations as a sponsor. I understand that the
information SSA discloses to DHS and DOS is for
official use for the purpose of administration of
federal laws regarding my obligation as a sponsor
and that DHS and DOS may disclose my information
as authorized by law; and

DRAFT
NOT FOR
PRODUCTION
06/22/2020
N.

I acknowledge that if I fail to meet the obligations of
sponsorship, I may be found ineligible to be a
sponsor in the future.

Sponsor's Signature

6.a. Sponsor's Signature

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

Subscribed and sworn to (or affirmed) before me this
day of

(Month),

(Year) at

,

My commission expires on (mm/dd/yyyy)

Signature of Notary Public

Notary Public Stamp
I understand that the information that agencies and
entities that administer or oversee means-tested
public benefits, and any agency or entity that is
authorized to act on its behalf, disclose to DHS and
DOS is for official use only to administer federal
laws regarding my support obligations as a sponsor,
and that DHS and DOS may disclose my information
only as authorized by law;

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 DOS may deny your affidavit.

Form I-864 03/06/18

Page 9 of 12

Part 10. Interpreter's Contact Information,
Certification, and Signature

Part 10. Interpreter's Contact Information,
Certification, and Signature (continued)

Provide the following information about the interpreter.

Interpreter's Signature

Interpreter's Full Name

7.a. Interpreter's Signature

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

DRAFT
NOT FOR
PRODUCTION
06/22/2020
7.b. Date of Signature (mm/dd/yyyy)

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

2.

Part 11. Contact Information, Certificaition, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor

Interpreter's Business or Organization Name (if any)

Provide the following information about the preparer.

Interpreter's Mailing Address

Preparer's Full Name

3.a. Street Number and Name

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

3.b.

Apt.

Ste.

Flr.

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

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

Province

3.e. ZIP Code

2.

Preparer's Business or Organization Name (if any)

3.g. Postal Code

Preparer's Mailing Address

3.h. Country

3.a. Street Number and Name

3.b.

Interpreter's Contact Information
4.

Apt.

3.d. State
Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

Flr.

3.c. City or Town

Interpreter's Daytime Telephone Number

5.

Ste.

3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Certification
Preparer's Contact Information

I certify, under penalty of perjury, that:
I am fluent in English and
which is the same language specified in Part 8., Item Number
1.b., and I have read to this sponsor in the identified language
every question and instruction on this affidavit and his or her
answer to every question. The sponsor informed me that he or
she understands every instruction, question, and answer on the
affidavit, including the Sponsor's Certification, and has
verified the accuracy of every answer.
Form I-864 03/06/18

,

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

Page 10 of 12

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.

DRAFT
NOT FOR
PRODUCTION
06/22/2020

NOTE: If you are an attorney or accredited
representative, you may need 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 affidavit.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this affidavit at the request of the sponsor. The sponsor
then reviewed this completed affidavit and informed me that he
or she understands all of the information contained in, and
submitted with, his or her affidavit, including the Sponsor's
Certification, and that all of this information is complete, true,
and correct. I completed this affidavit based only on information
that the sponsor 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-864 03/06/18

Page 11 of 12

5.a. Page Number

Part 12. 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. 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.

DRAFT
NOT FOR
PRODUCTION
06/22/2020

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

4.d.

Form I-864 03/06/18

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.c. Item Number

7.a. Page Number

7.d.

Page 12 of 12