Current Page Number and
Section
|
Current Text
|
Proposed
Text
|
Page 1,
For Government Use
Only
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[Page 1]
For Government Use Only
This Form I-864EZ:
[] DOES NOT MEET the
requirements of INA section 213A
[] MEETS the requirements of
INA section 213A
Reviewed By:
Location:
Date (mm/dd/yyyy):
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)
|
[Page 1]
For Government Use Only
This Form I-864EZ:
[] DOES NOT MEET the
requirements of INA section 213A
[] MEETS the requirements of
INA section 213A
Reviewed By:
Location:
Date (mm/dd/yyyy):
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)
|
Page 1,
Part 1. Qualifying
to Use Form I-864EZ
|
[Page 1]
START HERE - Type or print in
black ink.
Part 1. Qualifying
to Use Form I-864EZ
1.a. I am the petitioner of
the family member sponsored on this affidavit. [] Yes [] No
1.b. I am using my own earned
or retirement income, which is documented using Internal Revenue
Service (IRS) Form W-2. []Yes []No
1.c. The sponsored immigrant
is the only person immigrating based on the underlying visa
petition. [] Yes [] No
|
[Page 1]
START HERE - Type or print in
black ink.
Part 1. Qualifying
to Use Form I-864EZ
1.
I am the petitioner of the family member sponsored on this
affidavit. [] Yes [] No
2.
I am using my own earned or retirement income, which is
documented using Internal Revenue Service (IRS) Form W-2. []Yes
[]No
3.
The sponsored immigrant is the only person immigrating based
on the underlying visa petition. [] Yes [] No
|
|
[Used to be Part 3. Moved here and modified for 1C
numbering format.
Also, the WG deleted former Item Number 7. City or Town
of Birth and Item Number 8. State or Province of Birth (if
applicable).]
|
Part 2. Information About
You (Sponsor)
1. Family
Name (Last Name)
Given Name
(First Name)
Middle Name
(if applicable)
2.
Current Mailing Address
In Care
Of Name
Street Number
and Name
Apt.
Ste. Flr. Number
City or
Town
State
ZIP Code
Province
Postal Code
Country
3. Is your current mailing
address the same as your physical address? [] Yes [] No
If you answered "No" to
Item Number 3., provide your physical address below.
4.
Physical Address
Street Number
and Name
Apt.
Ste. Flr. Number
City or
Town
State
ZIP Code
Province
Postal Code
Country
Other
Information
5. Country of Domicile
6. Date of Birth
(mm/dd/yyyy)
7. Country
of Birth
8. U.S.
Social Security Number (Required)
9.
Immigration Status
[] I
am a U.S. citizen.
[] I
am a lawful permanent resident.
[] I am
a U.S. national.
10.
Sponsor’s A-Number (if any)
11. USCIS Online Account
Number (if any)
Military
Service
12.
I am currently
on active duty in the United States Armed Forces or U.S.
Coast Guard. [] Yes [] No
|
Page 1,
Part 2. Information
About the Immigrant You Are Sponsoring (Intending Immigrant)
|
[Page 1]
Part 2. Information About the
Immigrant You Are Sponsoring (Intending Immigrant)
Name of Immigrant
1.a. Family Name (Last Name)
1.b. Given Name (First Name)
1.c. Middle Name
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
2.h. Postal Code
2.i. Country
Other Information
3. Daytime Telephone Number
[new]
4. Date of Birth (mm/dd/yyyy)
5. Alien Registration Number
(A-Number) (if any)
6. USCIS Online Account
Number (if any)
7. U.S. Social Security
Number (if any)
|
Part
3. Information About
the Immigrant You Are Sponsoring (Intending Immigrant)
1.
Name of Immigrant
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
2. Current
Mailing Address
In Care
Of Name
Street
Number and Name
Apt.
Ste. Flr.
City or
Town
State
ZIP
Code
Province
Postal
Code
Country
Other
Information
[Renumbered. Now Item Number 7.]
3. Country
of Citizenship or Nationality
[no change]
6. USCIS Online Account
Number (if any)
[deleted]
7. Daytime
Telephone Number
|
Page 2,
Part 3. Information
About You (Sponsor)
|
[Page 2]
Part 3. Information About You
(Sponsor)
1.a. Family Name (Last Name)
1.b. Given Name (First Name)
1.c. Middle Name
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
2.h. Postal Code
2.i. Country
3. Is your current mailing
address the same as your physical address? [] Yes [] No
If you answered "No" to
Item Number 3., provide your physical address below.
Physical Address
4.a. Street Number and Name
4.b. Apt. Ste. Flr.
4.c. City or Town
4.d. State
4.e. ZIP Code
4.f. 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
(if applicable)
9. Country of Birth
10. U.S. Social Security
Number (Required)
11. USCIS Online Account
Number (if any)
Citizenship or Nationality
12. I am a U.S. citizen.
13.a. I am a lawful permanent
resident.
13.b. My alien registration
number is:
14. I am a U.S. national.
Military Service
15. I am
currently on active duty in the United States Armed Forces
or U.S. Coast Guard. [] Yes [] No
|
[Moved up in the FRM. Now Part
2.]
|
Page 2,
Part 4. Information
About Your Household Size
|
[Page 2]
Part 4. Information About Your
Household Size
NOTE: Do not count any
household member more than once.
1.a. Yourself and the person
you are sponsoring on this Form I-864EZ.
1.b. Your spouse.
1.c. Your dependent children
under 21 years of age.
1.d. If you have sponsored
any other persons on a Form I-864 who are now lawful permanent
residents in the United States, enter the number here.
1.e. If you have any other
dependents listed on your most recent Federal income tax return,
enter the number here.
1.f. Add together Item
Numbers 1.a. - 1.e. and enter the number here. This is
your HOUSEHOLD SIZE for the purpose of this Form I-864EZ.
|
Part 4. Information About Your
Household Size
NOTE: Do not count any
household member more than once.
1.
Yourself and the person you are sponsoring on this Form
I-864EZ.
2.
Your spouse. (NOTE:
Enter “0” if you already counted your spouse in Item
Number 1.)
3.
Your dependent children under 21 years of age. (NOTE:
Enter “0” if you already counted your dependent
children in Item Number 1.)
4.
If you have sponsored any other persons on a Form I-864 who
are now lawful permanent residents in the United States
and you are still obligated to support enter the number
here. (NOTE:
Enter “0” if you already counted these persons in Item
Number 1.)
5.
If you have any other dependents listed on your most recent
Federal income tax return, enter the number here. (NOTE:
Enter “0” if you
already counted your other dependents in Item
Number 1.)
6. Add together
Item Numbers 1. - 5.
and enter the number here. This is your HOUSEHOLD SIZE for the
purpose of this Form I-864EZ.
|
Page 3,
Part 5. Information
About Your Employment and Income
|
[Page 3]
Part 5. Information About Your
Employment and Income
1. I am currently:
[] Employed (Complete Item
Numbers 2.a. – 2.c.)
[] Retired (Complete Item Numbers
3.a. – 3.b.)
2.a. Current Occupation
2.b. Name of Employer 1
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 $
Federal Income Tax Information
5.a. Have you filed a Federal
income tax return for each of the three most recent tax years?
[] Yes [] No
NOTE: You MUST attach a
photocopy or transcript of your Federal income tax return for only
the most recent tax year.
5.b. (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 (adjusted gross
income on IRS Form 1040EZ) as reported on my Federal income tax
returns for the most recent three years was:
Tax Year Total Income
6.a. Most Recent $
6.b. 2nd Most Recent $
6.c. 3rd Most Recent $
|
Part 5. Information About Your
Employment and Income
1. I am currently:
[] Employed (Complete Item Number
2.)
[] Retired (Complete Item Number
3.)
2.
Current Occupation
Name of
Employer 1
Name of
Employer 2 (if applicable)
[deleted]
3.
Date of Retirement (mm/dd/yyyy)
[no change]
Federal
Income Tax Information
5.
Have you filed a Federal income tax return for each of the
three most recent tax years? [] Yes [] No
NOTE: You MUST attach a
photocopy or transcript of your Federal income tax return for only
the most recent tax year.
[deleted]
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:
Tax Year Total Income
6.
Most Recent
Tax
Year[Text Field] Total Income $[Text Field]
2nd
Most Recent Tax Year[Text Field]
Total Income $[Text Field]
3rd
Most Recent Tax Year[Text Field]
Total Income $[Text Field]
|
Pages 3-5,
Part 6. Sponsor’s
Contract, Statement, Contact Information, Declaration,
Certification, and Signature
|
[Page 3]
Part 6. Sponsor's Contract,
Statement, Contact Information, Declaration, Certification, and
Signature
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.
What Is the Legal Effect of
Signing Form I-864EZ?
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.
…
What If I Choose Not to Sign
Form I-864EZ?
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:
…
[Page 4]
What Other Consequences Are
There?
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
…
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.
…
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:
…
|
Part 6. Sponsor's Contract,
Statement, Contact Information, Declaration, Certification, and
Signature
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.
What Is the
Legal Effect of Signing Form I-864EZ?
[no change]
…
What If I
Choose Not to Sign Form I-864EZ?
[no change]
What Does
Signing Form I-864EZ Require Me to Do?
[no change]
…
What Other
Consequences Are There?
[no change]
…
What If I
Do Not Fulfill My Obligations?
[no change]
…
When Will
These Obligations End?
[no change]
…
|
Pages 5-6,
Part 7.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 5]
Part 7. Interpreter's Contact
Information, Certification, and Signature
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.e. ZIP Code
3.f. 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)
Interpreter's Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [Fillable
Field], which is the same language specified in Part 6.,
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 6]
Interpreter's Signature
7.a. Interpreter's Signature
7.b. Date of Signature
(mm/dd/yyyy)
|
Part 7. Interpreter's Contact
Information, Certification, and Signature
[deleted]
Interpreter’s
Full Name
1.
Interpreter’s Family Name (Last Name)
Interpreter’s
Given Name (First Name)
2.
Interpreter’s Business or Organization Name
[deleted]
Interpreter’s
Contact Information
3.
Interpreter’s Daytime Telephone Number
4.
Interpreter’s Mobile Telephone Number (if any)
5.
Interpreter’s Email Address (if any)
Interpreter’s
Certification and Signature
I
certify, under penalty of perjury, that I
am fluent in English and [Fillable language field], and I have
interpreted every question on the affidavit
and Instructions and interpreted the sponsor’s answers to
the questions in that language, and the sponsor
informed me that they understood
every instruction, question, and answer on the affidavit.
[deleted]
6.
Interpreter’s Signature
Date of
Signature (mm/dd/yyyy)
|
Page 6,
Contact Information,
Declaration, and Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor
|
[Page 6]
Part 8. Contact
Information, Declaration, and Signature of the
Person Preparing this Affidavit, if Other Than the Sponsor
Provide the following
information about the preparer.
Preparer's Full Name
1.a. Preparer's Family Name
(Last Name)
1.b. Preparer's Given Name
(First Name)
2. Preparer's Business or
Organization Name (if any)
Preparer's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. 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)
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.
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 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.
Preparer’s Signature
8.a. Preparer’s
Signature
8.b. Date of Signature
(mm/dd/yyyy)
|
Part 8. Contact
Information, Declaration, and Signature of the
Person Preparing this Affidavit, if Other Than the Sponsor
[deleted]
Preparer’s
Full Name
1.
Preparer’s Family Name (Last Name)
Preparer’s
Given Name (First Name)
2. Preparer’s Business
or Organization Name
[deleted]
Preparer’s
Contact Information
3.
Preparer’s Daytime Telephone Number
4.
Preparer’s Mobile Telephone Number (if any)
5.
Preparer’s Email Address (if any)
[deleted]
Preparer’s
Certification and Signature
I certify,
under penalty of perjury, that I prepared this affidavit for the
sponsor at their request and with express consent and that all of
the responses and information contained in and submitted with the
affidavit are complete, true, and correct and reflects only
information provided by the sponsor. The sponsor reviewed the
responses and information and
informed me that they understand the responses and information in
or submitted with the affidavit.
[deleted]
6.
Preparer’s Signature
Date of
Signature (mm/dd/yyyy)
|
Page 7,
Part 9. Additional
Information
|
[Page 7]
Part 9. 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. A-Number (if any)
3.a. Page Number
3.b. Part Number
3.c. Item Number
3.d. [fillable lines]
4.a. Page Number
4.b. Part Number
4.c. Item Number
4.d. [fillable lines]
5.a. Page Number
5.b. Part Number
5.c. Item Number
5.d. [fillable lines]
6.a. Page Number
6.b. Part Number
6.c. Item Number
6.d. [fillable lines]
7.a. Page Number
7.b. Part Number
7.c. Item Number
7.d. [fillable lines]
|
Part 9. 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.
Family Name (Last Name)
Given
Name (First Name)
Middle
Name
2. A-Number (if any)
3.
Page Number
Part
Number
Item
Number
[fillable
lines]
4.
Page Number
Part
Number
Item
Number
[fillable
lines]
5.
Page Number
Part
Number
Item
Number
[fillable
lines]
6.
Page Number
Part
Number
Item
Number
[fillable
lines]
7.
Page Number
Part
Number
Item
Number
[fillable lines]
|