I-864EZ Affiavit of Support of Support Under Section 213A of the

Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-864EZ
OMB No. 1615-0075
Expires 03/31/2021

For Government Use Only
This Form I-864EZ:
DOES NOT MEET
the requirements of
INA section 213A

MEETS the
requirements of
INA section 213A

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

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

Reviewed By:
Location:

Date (mm/dd/yyyy):

Attorney State Bar Number
(if applicable)

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

DRAFT
Not for
Production
08/17/2020

► START HERE - Type or print in black ink.

Part 1. Qualifying to Use Form I-864EZ

Mailing Address

1.a. I am the petitioner of the family member sponsored on
this affidavit.
Yes
No (Use Form I-864)

2.a. In Care Of Name

1.b. I am using my own earned or retirement income, which is
documented using Internal Revenue Service (IRS) Form
W-2.
Yes
No (Use Form I-864)
1.c. The sponsored immigrant is the only person immigrating
based on the underlying visa petition.
Yes

No (Use Form I-864)

2.b. Street Number and Name

2.c.

Apt.

Part 2. Information About the Immigrant You
Are Sponsoring (Intending Immigrant)

2.g. Province

Name of Immigrant

2.h. Postal Code

1.c. Middle Name

Form I-864EZ 03/06/18

Flr.

2.d. City or Town

2.e. State

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

Ste.

2.i.

2.f.

ZIP Code

Country

Other Information

3.

Daytime Telephone Number

4.

Date of Birth (mm/dd/yyyy)

5.

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

6.

USCIS Online Account Number (if any)
►

7.

U.S. Social Security Number (if any)
►

Page 1 of 9

Part 3. Information About You (Sponsor)

6.

Date of Birth (mm/dd/yyyy)

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

7.

City or Town of Birth

8.

State or Province of Birth (if applicable)

9.

Country of Birth

10.

U.S. Social Security Number (Required)
►

1.c. Middle Name

Mailing Address
2.a. In Care Of Name

DRAFT
Not for
Production
08/17/2020

2.b. Street Number and Name

2.c.

Apt.

Ste.

11.

USCIS Online Account Number (if any)
►

Flr.

Citizenship or Nationality

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

2.f.

12.

I am a U.S. citizen.

13.a.

I am a lawful permanent resident.

13.b. My alien registration number is:
► A-

2.g. Province
2.h. Postal Code
2.i.

ZIP Code

14.

Country

I am a U.S. national.

Military Service

3.

Is your current mailing address the same as your physical
address?
Yes
No

15.

I am currently on active duty (other than active duty for
training) in the United States Armed Forces.

If you answered "No" to Item Number 3., provide your
physical address below.

Yes

No

Part 4. Information About Your Household Size

Physical Address

4.a. Street Number and Name

NOTE: Do not count any household member more than once.
1.a. Yourself and the person you are sponsoring on this Form
I-864EZ.

4.b.

Apt.

Ste.

Flr.
1.b. Your spouse.

4.c. City or Town
1.c. Your dependent children under 21 years of age.
4.d. State
4.f.

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

Other Information
5.

Country of Domicile

Form I-864EZ 03/06/18

1.d. If you have sponsored any other persons on a Form I-864
or Form I-864EZ who either have pending applications
for permanent residence, or who are now lawful
permanent residents in the United States, and for whom
your support obligation has NOT ended, enter the number
here.
1.e. If you have executed a Form I-864A for persons who
have pending applications for permanent residence or
who are now lawful permanent residents and for whom
your support obligation has NOT ended, enter the number
here.

Page 2 of 9

Part 4. Information About Your Household Size
(continued)

Part 6. Information About Your Employment
and Income

1.f.

1.

If you have any other dependents listed on your most
recent Federal income tax return, enter the number here.

I am currently:
Employed (Complete Item Numbers 2.a. - 2.c.)
Retired (Complete Item Numbers 3.a. - 3.b.)

1.g. Add together Item Numbers 1.a. - 1.f. and enter the
number here. This is your HOUSEHOLD SIZE for the
purpose of this Form I-864EZ.

2.a. Current Occupation

2.b. Name of Employer 1

Part 5. Previously Executed Form I-864, Form
I-864EZ, or Form I-864A
1.

2.

DRAFT
Not for
Production
08/17/2020

I have executed Form I-864, Form I-864EZ, or Form
I-864A for any individuals other than those named on this
form.
Yes
No
I have sponsored the following individual(s) by
submitting Form I-864, Form I-864EZ, or Form I-864A
and my support obligation for these individuals has NOT
ended:

2.c. Name of Employer 2 (if applicable)

3.a. Name of Former Employer

3.b. Date of Retirement (mm/dd/yyyy)
4.

My current individual annual income $

Sponsored Individual 1
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

Federal Income Tax Information

5.

4.

Date of Birth (mm/dd/yyyy)

5.

Alien Registration Number
► A-

Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No
NOTE: You MUST attach Internal Revenue Service
(IRS)-issued certified copies or transcripts of your Federal
income tax return for the three most recent tax years.

My total income (adjusted gross income on IRS Form 1040EZ)
as reported on my Federal income tax returns for the most recent
three years was:

Sponsored Individual 2
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

Tax Year

Total Income

6.a. Most Recent

$

6.b. 2nd Most Recent

$

6.c. 3rd Most Recent

$

6.c. Middle Name

Sponsor's Bank Account Information
7.

Date of Birth (mm/dd/yyyy)

8.

Alien Registration Number

Account Type
► A9.

Have you ever had to reimburse an agency for any meanstested public benefits issued to a sponsored immigrant on
whose behalf you executed a Form I-864, Form I-864EZ,
or Form I-864A?
Yes
No
If you answered “Yes” to Item Number 9., provide an
explanation, including the name of the agency that you
reimbursed and the amount you had to reimburse, in Part
10. Additional Information. Provide evidence that you
have fully reimbursed the amount owed.

Form I-864EZ 03/06/18

7.a.

Checking

7.b.

Savings

Account Holder
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c. Middle Name

Page 3 of 9

Part 6. Information About Your Employment
and Income (continued)

What Is the Legal Effect of Signing Form
I-864EZ?

Joint Account Holder (if any)

If you sign Form I-864EZ on behalf of any person (intending
immigrant) who is applying for an immigrant visa or adjustment
of status to a lawful permanent resident, and that intending
immigrant submits Form I-864EZ 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.

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

Institution Name

11.

Account Number

12.

Routing Number

Under this contract, you agree that, in deciding whether the
intending immigrant can establish that he or she is not
inadmissible to the United States as a foreign national likely to
become a public charge, the U.S. Government can consider
your income and assets available for the support of the
intending immigrant.

DRAFT
Not for
Production
08/17/2020

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

Credit Report Information

Provide documentation as provided in the Instructions.
13.

Do you have a U.S. credit report and credit score
available?
Yes

No

If you answered “Yes” to Item Number 13., provide a
copy of a U.S. credit report and credit score generated
within the last 12 months prior to the date of filing. If you
answered “No” to Item Number 13., provide a credit
agency report that demonstrates that you do not have a
credit record or score.

Part 7. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature

You cannot be made to sign Form I-864EZ if you do not want
to do so. But if you do not sign Form I-864EZ, the intending
immigrant may not be able to become a lawful permanent
resident in the United States.

What Does Signing Form I-864EZ Require Me to
Do?

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

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 his or her household size (or 100
percent if you are the sponsor and are on active duty
in the U.S. Armed Forces and the person is your
husband, wife, or unmarried child under 21 years of
age.); and

B.

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. Please
see the USCIS website at www.uscis.gov/I-865 for
more information on filing a change of address as a
sponsor.

NOTE: Read the Penalties section of the Form I-864EZ
Instructions before completing this part.

By signing this Form I-864EZ, 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-864EZ. If you do not understand the obligations, you may
wish to consult an attorney or accredited representative.

Form I-864EZ 03/06/18

Page 4 of 9

Part 7. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)

B.

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

C.

No longer has lawful permanent resident status and
has departed the United States;

What Other Consequences Are There?

D.

Becomes 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.

If an intending immigrant becomes a lawful permanent resident
in the United States based on a Form I-864EZ that you have
signed, then, until your obligations under Form I-864EZ
terminate, your income and assets may be considered available
to that person, 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 of your income
and assets as available to the person.

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

DRAFT
Not for
Production
08/17/2020

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 programs under the
Elementary and Secondary Education Act.

Your obligations under Form I-864EZ also end if you die.
Therefore, if you die, your estate will not be required to take
responsibility for the person's support after your death. Your
estate may, however, be responsible for any support that you
owed before you died.

Sponsor's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.a.

I can read and understand English, and 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 8. read to me every
question and instruction on this affidavit and my
answer to every question in

What If I Do Not Fulfill My Obligations?

If you do not provide sufficient support to the person who
becomes a lawful permanent resident based on the Form
I-864EZ that you signed, that person may sue you for this
support.

If a Federal, state, local, or a private agency provides any
covered means-tested public benefit to the person who becomes
a lawful permanent resident based on the Form I-864EZ that you
signed, the agency may ask you to reimburse them 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 are sued, and the court enters a judgment against you, the
person 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. Please see the USCIS website at
www.uscis.gov/I-865 for more information on filing a change
of address as a sponsor.

,

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

2.

At my request, the preparer named in Part 9.,
,

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)

When Will These Obligations End?
Your obligations under Form I-864EZ will end if the person
who becomes a lawful permanent resident based on a Form
I-864EZ that you signed:
A.

Becomes a U.S. citizen;

Form I-864EZ 03/06/18

Page 5 of 9

Part 7. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Sponsor's Declaration and 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 of my records that USCIS or DOS may need to
determine my eligibility for the immigration benefit I seek.

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

B.

C.

D.

6.a. Sponsor's Signature

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

Part 8. Interpreter's Contact Information,
Certification, and Signature

DRAFT
Not for
Production
08/17/2020

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.

A.

Sponsor's Signature

I know the contents of this affidavit of support that I
signed;
I have read and I understand each of the obligations
described in Part 6., and I agree, freely and without
any mental reservation or purpose of evasion, to
accept each of those obligations in order to make it
possible for the immigrant indicated in Part 2. to
become a lawful permanent resident of the United
States;
I agree to submit to the personal jurisdiction of any
Federal or state court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864EZ;

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;

E.

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-864EZ; and

F.

I authorize the Social Security Administration to
release information about me in its records to the
USCIS and DOS.

Form I-864EZ 03/06/18

Provide the following information about the interpreter.

Interpreter's Full Name

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

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

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3.a. Street Number and Name

3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

Page 6 of 9

Part 8. Interpreter's Contact Information,
Certification, and Signature (continued)

Preparer's Mailing Address
3.a. Street Number and Name

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 7., 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 Declaration and
Certification, and has verified the accuracy of every answer.

3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

DRAFT
Not for
Production
08/17/2020
3.g. Postal Code
3.h. Country

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

Preparer's Contact Information

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

4.

Preparer's Daytime Telephone Number

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Provide the following information about the preparer.

Preparer's Full Name

Preparer's Statement

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

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.

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

2.

Preparer's Business or Organization Name (if any)

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

Form I-864EZ 03/06/18

Page 7 of 9

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor (continued)
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 Declaration and 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.

DRAFT
Not for
Production
08/17/2020

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

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

Form I-864EZ 03/06/18

Page 8 of 9

5.a. Page Number

Part 10. 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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
Not for
Production
08/17/2020

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

3.d.

4.a. Page Number

3.c. Item Number

4.b. Part Number

4.d.

Form I-864EZ 03/06/18

4.c. Item Number

7.a. Page Number

7.d.

Page 9 of 9