G-1563 Request for Certified Copy of Affidavit of Support Under

Request for Certified Copy of Affidavit of Support
Under Section 213A of the INA or
Contract Between Sponsor and Household Member
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form G-1563
OMB No. 1615-xxxx
Expires xx/xx/20xx

► START HERE - Type or print in black ink.
Answer all questions fully and accurately. If a question does not apply to you, type or print “N/A” unless otherwise directed. If
the answer to a question which requires a numeric response is zero or none, type or print “None” unless otherwise directed.

Part 1. Requestor is the Sponsored Alien
Complete this Part if you are a sponsored alien requesting a certified copy of the Affidavit of Support Under Section 213A of the INA
(Form I-864 or Form I-864EZ) (“Affidavit”) or the Contract Between Sponsor and Household Member (Form I-864A) (“Contract”)
executed on your behalf.
1.

Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

2.

Date of Birth (mm/dd/yyyy)

Given Name (First Name)

3.

Male
5.

Country of Birth

7.

Current Mailing Address

4.

Gender
Female
6.

Middle Name

Alien Registration Number (A-Number)
► A-

Country of Citizenship or Nationality

In Care Of Name

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Part 2. Requestor on behalf of Agency or Entity
Complete this Part if you are requesting a certified copy of the Affidavit or Contract on behalf of a Federal, State, or local government
agency, or other entity that administers a means-tested public benefit program.
1.

Agency Contact's Full Name
Family Name (Last Name)

2.

Given Name (First Name)

Name of Benefit Granting Agency

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Part 2. Requestor on behalf of Agency or Entity (continued)
3.

Agency Contact's Mailing Address
In Care Of Name

4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Full Legal Name of Sponsored Alien Who Received Means-tested Public Benefits
Family Name (Last Name)

Given Name (First Name)

5.

Sponsored Alien's Date of Birth (mm/dd/yyyy)

6.

Sponsored Alien's Gender

7.

Sponsored Alien's Alien Registration Number (A-Number) ► A-

Male

Middle Name

Female

Part 3. Requestor is a Sponsor or Household Member
Complete this Part if you are a sponsor, or a household member who executed a Contract, who is requesting a certified copy of the
Affidavit that you executed or that relates to your support obligation, or of a Contract that you executed on behalf of a sponsored alien.
1.

Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

2.

Date of Birth (mm/dd/yyyy)

3.

Current Mailing Address

Given Name (First Name)

Middle Name

In Care Of Name

4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Full Legal Name of Sponsored Alien
Family Name (Last Name)

Given Name (First Name)

5.

Sponsored Alien's Date of Birth (mm/dd/yyyy)

6.

Sponsored Alien's Gender

7.

Sponsored Alien's Alien Registration Number (A-Number) ► A-

G-1563 xx/xx/xx

Male

Middle Name

Female

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Part 4. Type of Document Requested
Select which type of document you are requesting:
Affidavit of Support Under Section 213A of the INA (Form I-864 or Form I-864EZ)
Contract Between Sponsor and Household Member (Form I-864A)
Both

Part 5. Reason for Request
Select a reason for why you are requesting the document(s) selected in Part 4.
For use in any action to enforce an Affidavit of Support Under Section 213A of the INA (Form I-864 or Form I-864EZ) or
Contract Between Sponsor and Household Member (Form I-864A)
For use in a reimbursement request for a sponsor and/or household member
Other (explain):

Part 6. Sponsored Alien Requestor Statement, Contact Information, Certification and Signature
Complete this Part if you filled out Part 1. Requestor is the Sponsored Alien.

Sponsored Alien's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Sponsored Alien's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this form and my
answer to every question.

B.

The interpreter named in Part 9. read to me every question and instruction on this form and my answer to every
question in

2.

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

At my request, the preparer named in Part 10.,

,

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

Sponsored Alien's Contact Information
3.

Daytime Telephone Number

5.

Email Address (if any)

G-1563 xx/xx/xx

4.

Mobile Telephone Number (if any)

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Part 6. Sponsored Alien Requestor Statement, Contact Information, Certification and Signature
(continued)
Sponsored Alien's Certification
I certify, under penalty of perjury, that to the best of my knowledge and belief, all of the information contained in, and submitted with
this form, is complete, true, and correct.
6.

Signature

Date of Signature (mm/dd/yyyy)

Part 7. Requestor on behalf of Agency or Entity Contact Information, Certification and Signature
Complete this Part if you filled out Part 2. Requestor on behalf of Agency or Entity.

Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Requestor's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this form and my
answer to every question.

B.

The interpreter named in Part 9. read to me every question and instruction on this form and my answer to every
question in

2.

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

At my request, the preparer named in Part 10.,

,

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

Contact Information
3.

Requestor's Contact's Daytime Telephone Number

5.

Requestor's Contact's Email Address

4.

Requestor's Contact's Mobile Telephone Number

Certification
I certify, under penalty of perjury, that to the best of my knowledge and belief, all of the information contained in, and submitted with
this form, is complete, true, and correct.
I am filing this form on behalf of a benefit agency or entity and certify that I am authorized to do so by the agency or entity.
6.

Agency or Entity Contact Signature

G-1563 xx/xx/xx

Date of Signature (mm/dd/yyyy)

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Part 8. Sponsor or Household Member Who Executed Contract Between Sponsor and Household
Member Requestor Statement, Contact Information, Certification and Signature
Complete this Part if you filled out Part 3. Requestor is a Sponsor or Household Member.

Sponsor or Household Member Who Executed Contract Between Sponsor and Household Member Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Sponsor or Household Member's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this form and my
answer to every question.

B.

The interpreter named in Part 9. read to me every question and instruction on this form and my answer to every
question in

2.

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

At my request, the preparer named in Part 10.,

,

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

Sponsor or Household Member Who Executed Contract Between Sponsor and Household Member Contact
Information
3.

Daytime Telephone Number

5.

Email Address (if any)

4.

Mobile Telephone Number (if any)

Sponsor or Household Member Who Executed Contract Between Sponsor and Household Member
Certification
I certify, under penalty of perjury, that to the best of my knowledge and belief, all of the information contained in, and submitted with
this form, is complete, true, and correct.
6.

Signature

Date of Signature (mm/dd/yyyy)

Part 9. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

G-1563 xx/xx/xx

Interpreter's Given Name (First Name)

Page 5 of 8

Part 9. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and

, which is the same language specified in Part 6., Item B.

in Item Number 1., Part 7., Item B. in Item Number 1., or Part 8., Item B. in Item Number 1. and I have read to the requestor in the
identified language every question and instruction on this declaration and his or her answer to every question. The requestor informed
me that he or she understands every instruction, question, and answer on the form and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature (sign in ink)

Date of Signature (mm/dd/yyyy)

Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Form
Provide the following information about the interpreter.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

G-1563 xx/xx/xx

Preparer's Given Name (First Name)

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Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Form (continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this form on behalf of the requestor submitting this
form.

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 form.
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, with this application.

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

Preparer's Signature
8.

Preparer's Signature

G-1563 xx/xx/xx

Date of Signature (mm/dd/yyyy)

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Part 11. Additional Information
If you need extra space to provide any additional information with this request, use the space below. If you need more space than 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.
1.

Family Name (Last Name)

2.

A-Number ► A-

3.

A. Page Number

Given Name (First Name)

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

Middle Name

D.

4.

A. Page Number

D.

5.

A. Page Number

D.

6.

A. Page Number

D.

7.

A. Page Number

D.

G-1563 xx/xx/xx

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