Form I 864Ez – Fill Out and Use This PDF

DOES NOT MEET the requirements of INA section 213A

	MEETS the	Reviewed By:
	requirements of	Location:	Date (mm/dd/yyyy):
	INA section 213A

Part 1. Qualifying to Use Form I-864EZ

1.a. I am the petitioner of the family member sponsored on

this affidavit.	Yes	No (Use Form I-864)

1.b. I am using my own earned or retirement income, which is documented using Internal Revenue Service (IRS) Form

W-2.

Yes

1.c. The sponsored immigrant is the only person immigrating based on the underlying visa petition.

Mailing Address

2.a. In Care Of Name

2.b. Street Number

and Name

2.c. Apt. Ste. Flr.

2.d. City or Town

Yes	No (Use Form I-864)

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

Name of Immigrant

1.a. Family Name

(Last Name)

2.e. State

2.g. Province

2.h. Postal Code 2.i. Country

2.f. ZIP Code

1.b. Given Name (First Name)

1.c. Middle Name

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)

►

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

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:

► A-

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

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.

2

1.b. Your spouse.

1.c. Your dependent children under 21 years of age.

4.d. State

4.f. Province

4.g. Postal Code

4.h. Country

4.e. ZIP Code

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

Other Information

5.Country of Domicile

6.Date of Birth (mm/dd/yyyy)

purpose of this Form I-864EZ.

2

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 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.

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.

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:

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 petitioning sponsor and are on active duty in the U.S. Armed Forces or U.S. Coast Guard 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.

Part 6. Sponsor's Contract, Statement, Contact

Information, Declaration, Certification, and

Signature (continued)

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.

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?

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.

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;

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;

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.

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

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 7. read to me every
	question and instruction on this affidavit and my
	answer to every question in
		,
	a language in which I am fluent, and I understood
	everything.
2.	At my request, the preparer named in Part 8.,
		,
	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 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.

Part 6. 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.

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.

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 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;
C.	I agree to submit to the personal jurisdiction of any

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

	Federal or state court that has subject matter
	jurisdiction of a lawsuit against me to enforce my
	obligations under this Form I-864EZ;
D.	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

3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

3.e. ZIP Code

	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.

Sponsor's Signature

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.

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

,

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.

Part 7. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Signature

7.a. Interpreter's Signature

7.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

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

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.

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)

3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

3.e. ZIP Code

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)

► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.