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

For
USCIS
Use
Only

Affidavit of Support Submitter
Petitioner
1st Joint Sponsor
2nd Joint Sponsor
Substitute Sponsor
5% Owner

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

Section 213A Review
MEETS
requirements

Number of Support Affidavits in File

DOES NOT MEET
requirements

1

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Remarks

Reviewed By:
Office:
Date (mm/dd/yyyy):

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

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

2

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

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

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.

4.

Date of Birth (mm/dd/yyyy)

5.

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

Part 2. Information About the Principal
Immigrant

6.

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

USCIS Online Account Number (if any)
►

7.

Daytime Telephone Number

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

Page 1 of 11

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

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

2.

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)

Family Member 3
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)

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14.c. Middle Name
15.

Relationship to 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.)

16.

Date of Birth (mm/dd/yyyy)

17.

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

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

18.

► A-

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)

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)
►

► A-

8.

USCIS Online Account Number (if any)
►

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)

12.

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

13.

USCIS Online Account Number (if any)
►

Form I-864 03/06/18

USCIS Online Account Number (if any)
►

Family Member 5
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)

27.

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

28.

USCIS Online Account Number (if any)
►

Page 2 of 11

Part 3. Information About the Immigrants You
Are Sponsoring (continued)
29. 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.

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

4.b.

Apt.

Ste.

Flr.

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4.c. City or Town
4.d. State

4.f.

Part 4. Information About You (Sponsor)

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

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

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

9.

Country of Birth

10.

U.S. Social Security Number (Required)

1.c. Middle Name

Sponsor's Mailing Address
2.a. In Care Of Name

2.b. Street Number and Name

2.c.

Apt.

Ste.

Flr.

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

2.f.

►

ZIP Code

2.g. Province

Citizenship or Residency
11.a.

I am a U.S. citizen.

2.h. Postal Code

11.b.

I am a U.S. national.

2.i.

11.c.

I am a lawful permanent resident.

3.

Country

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

12.

Sponsor's A-Number (if any)
► A-

13.

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

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

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

Form I-864 03/06/18

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

Page 3 of 11

For
USCIS
Use
Only

Part 5. Sponsor's Household Size

Sponsored Individual 1

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

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

1.

3.c. Middle Name

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

Persons NOT sponsored in this affidavit:
2.

Yourself.

3.

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

4.

If you have dependent children, enter the number here.

5.

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

6.

7.

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

4.

Date of Birth (mm/dd/yyyy)

5.

A-Number

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

6.c. Middle Name

7.

Date of Birth (mm/dd/yyyy)

8.

A-Number

9.

Have you ever had to reimburse an agency for any meanstested public benefits issued to a sponsored immigrant on
whose behalf you executed Form I-864, Form I-864EZ, or
Form I-864A?
Yes
No

Household Size:

1.

I have executed a Form I-864, Form I-864EZ, or Form
I-864A for any individuals other than those named on this
form.
Yes
No

2.

I executed a Form I-864, Form I-864EZ, or Form I-864A
on behalf of the following individuals and my support
obligation for these individuals has NOT ended:

Form I-864 03/06/18

► A-

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
12. Additional Information. Provide evidence that you
have fully reimbursed the amount owed.

Add together Part 5., Item Numbers 1. - 6. and enter the
number here.

Part 6. Previously Executed Form I-864, Form
I-864EZ, or Form I-864A

► A-

10.

Have you ever had a judgment entered against you for
failing to fulfill your obligation under Form I-864, Form
I-864EZ, or Form I-864A?
Yes
No
If you answered “Yes” to Item Number 10., provide a
certified copy of the judgment against you.

Part 7. Sponsor's Employment and Income
I am currently:
1.

Employed as a/an

2.

Name of Employer 1

Page 4 of 11

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

For
USCIS
Use
Only

Poverty Guideline

Remarks

Year: 2 0
Poverty Line:
$

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Part 7. Sponsor's Employment and Income
(continued)
3.

16.

Name of Employer 2 (if applicable)

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

4.

Self-Employed as a/an (Occupation)

Federal Income Tax Return Information

17.

5.

Retired Since (mm/dd/yyyy)

6.

Unemployed Since (mm/dd/yyyy)

7.

My current individual annual income is:

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.

$

Income you are using from your spouse, and, 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

Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No

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

Total Income

18.a. Most Recent

$

18.b. 2nd Most Recent

$

18.c. 3rd Most Recent

$

19.

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.

$

Sponsor's Bank Account Information
Person 2

Account Type

11.

Name

12.

Relationship

20.a.

Checking

20.b.

Savings

Account Holder
13.

Current Income

14.

My Current Annual Household Income (Total all lines
from Part 6. Item Numbers 7., 10., and 13.; the total
will be compared to Federal Poverty Guidelines on Form
I-864P.)
$

15.

$

My spouse has executed Form I-864A. I am filing
along with this affidavit the necessary Form I-864A
completed by my spouse.

21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)
21.c. Middle Name
Joint Account Holder (if any)
22.a. Family Name
(Last Name)
22.b. Given Name
(First Name)
22.b. Middle Name

Form I-864 03/06/18

Page 5 of 11

For
USCIS
Use
Only

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

Poverty Guideline

Sponsor's Household Income

Remarks

(Page 5, Line 10)

Year: 2 0
Poverty Line:
$

$
The total value of all assets, line 10, must equal 5 times (3 times for spouses and children of
USC's, or 1 time for orphans or Convention adoptee considered to be coming to the United
States for adoption) the difference between the poverty guidelines and the sponsor's household
income, line 10.

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Part 7. Sponsor's Employment and Income
(continued)
23.

Institution Name

24.

Account Number

25.

Routing Number

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, Part 4., Item Number 3.d., for:
5.a. Name of Relative

Means-Tested Public Benefits
26.

I have received a means-tested public benefit within 36
months of executing this Form I-864 and I received that
means-tested public benefit on or after [EFFECTIVE
DATE OF RULE].
Yes
No

5.b. Your household member's assets from Form I-864A
(optional).
$
Assets of the principal sponsored immigrant (optional).

Credit Report and Credit Score Information
Provide documentation as provided in the Instructions.
27.

Do you have a U.S. credit report and credit score available?
Yes. Provide a copy of a U.S. credit report and credit
score generated within the last 12 months prior to the
date of filing.
No. Provide a credit agency report that demonstrates
that you do not have a credit report or score.

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 Number 14, exceeds the Federal Poverty
Guidelines for your household size, YOU ARE NOT
REQUIRED to complete this Part 8. Skip to Part 9.
Your Assets (Optional)

The principal sponsored immigrant is the person 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.
$

9.

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

Total Value of Assets

1.

Enter the balance of all savings and checking accounts.
$

2.

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

10.

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

$

Form I-864 03/06/18

Page 6 of 11

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

What if I have had a judgment entered against me for
failing to fulfill my obligations under a previous Form I-864,
Form I-864EZ, or Form I-864A?
If you have previously defaulted on a support obligation, as
shown by a court judgment ordering you to repay a meanstested public benefit paid to an alien whom you have or had a
support obligation as a sponsor or household member, you will
be considered unable to meet the income requirements of a
sponsor for purposes of this Form I-864. If you are the
petitioning sponsor or a substitute sponsor, you are still required
to execute the affidavit of support, but a joint sponsor who has
not previously defaulted on an affidavit of support obligation
and who can demonstrate the means to maintain income at the
applicable threshold must execute an additional affidavit of
support for the intending immigrant to avoid being found
inadmissible.

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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.
What if I have received a means-tested public benefit in the
past 36 months of filing this Form I-864?

In general, if you are a sponsor and have received a meanstested public benefit within 36 months of filing this Form I-864,
you will be not be able to meet the income requirements of a
sponsor under INA 213A(f)(1)(E). If you are the petitioning
sponsor or substitute sponsor, you are still required to execute
Form I-864, but the intending immigrant must submit Form
I-864 executed by a joint sponsor who has not received any
means-tested public benefit within 36 months of the joint
sponsor completing that Form I-864 in order for the intending
immigrant to avoid being found inadmissible.
NOTE: This requirement to have a joint sponsor execute a
Form I-864 due to receipt of means-tested public benefits only
applies to means-tested public benefits that you, the petitioning
sponsor, received on or after [EFFECTIVE DATE OF RULE].

If a petitioning sponsor who is on active duty (other than active
duty for training) in the U.S. Armed Forces received meanstested public benefits within 36 months of submitting Form
I-864, but is sponsoring his or her spouse or child under section
204 of the INA, a joint sponsor is not required due to receipt of
means-tested public benefits. A joint sponsor would be
required if the petitioning sponsor cannot demonstrate the
means to maintain income at least 100 percent of the FPG.

What is the Legal Effect of My Signing Form I-864?
If you sign Form I-864 on behalf of any person (called the
intending immigrant) who is applying for an immigrant visa or
for adjustment of status to 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.
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 person likely to become a
public charge, the U.S. Government can consider your income
and assets as available for the support of the intending
immigrant.
What If I Choose Not to Sign Form I-864?
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, until your obligations under Form I-864 terminate,
you must:

Form I-864 03/06/18

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 (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.
Page 7 of 11

Part 9. Sponsor's Contract, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
What Other Consequences Are There?

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.

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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 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
(deeming) of your income and assets as available to the person.
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.
What If I Do Not Fulfill My Obligations?

NOTE: Divorce does not terminate your obligations under
Form I-864.
Your obligations under a Form I-864 that you signed also end if
you die. Therefore, if you die, your estate is not required to
take responsibility for the person's support after your death.
However, your estate may owe any support that you
accumulated 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 10. read to me every
question and instruction on this affidavit and my
answer to every question in

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

,

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)

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

Becomes a U.S. citizen;

B.

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

C.

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

Form I-864 03/06/18

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 and all of my records that USCIS or DOS may need to
determine my eligibility for the benefit that I seek.

Page 8 of 11

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

I know the contents of this affidavit of support that I
signed;

B.

I have read and I understand each of the obligations
described in Part 9., 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 immigrants indicated in Part 3. to
become lawful permanent residents of the United
States;

D.

E.

F.

Provide the following information about the interpreter.

Interpreter's Full Name

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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.

C.

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

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-864;

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 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; and

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

Sponsor's Signature

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)

6.a. Sponsor's Signature

Interpreter's Certification
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 affidavit.

Form I-864 03/06/18

I certify, under penalty of perjury, that:
I am fluent in English and

,

which is the same language specified in Part 9., 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.
Page 9 of 11

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

Preparer's Statement
7.a.

Interpreter's Signature

I am not an attorney or accredited representative but
have prepared this affidavit on behalf of the sponsor
and with the sponsor's consent.
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
08/17/2020
7.b.

7.a. Interpreter's Signature

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

Part 11. Contact Information, Declaration, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor
Provide the following information about the preparer.

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.

Preparer's Full Name

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

Preparer's Certification

Preparer's Mailing Address

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.

3.a. Street Number and Name

Preparer's Signature

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

2.

Preparer's Business or Organization Name (if any)

8.a. Preparer's Signature

3.b.

Apt.

Ste.

Flr.

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

8.b. Date of Signature (mm/dd/yyyy)
3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Form I-864 03/06/18

Page 10 of 11

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
08/17/2020

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

1.c. Middle Name
2.

A-Number (if any)

► A-

6.a. Page Number

3.a. Page Number

3.b. Part Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number
4.a. Page Number

4.b. Part Number

4.c. Item Number
7.d.

4.d.

Form I-864 03/06/18

Page 11 of 11