USCIS Form I-864 (Affidavit of Support)

Part 1. Basis For Filing Affidavit of Support: check only one box, because you are the sponsor submitting this affidavit of support: I am the petitioner. I filed or am filing for the immigration of my relative.

Or check I filed an alien worker petition on behalf of the intending immigrant, who is related to me as my, and fill in the line.

Or check I have an ownership interest of at least 5 percent in, and fill in the line, which filed an alien worker petition on behalf of the intending immigrant, who is related to me as my.

Or check I am the only joint sponsor.

Or check I am the first or second of two joint sponsors.

Enter the Sponsor's Full Legal Name. Do not provide a nickname.

Enter the Sponsor's Current Mailing Address, with the In Care Of Name (if any).

Check Yes or No.

If you answered "No", provide the Sponsor's Physical Address: Street Number and Name, Flr., Ste., Apt. Number, City or Town, State, ZIP Code, Postal Code, Country, Province.

Under Other Information, enter the Country of Birth and the U.S. Social Security Number (Required).

Enter the Country of Domicile and the Date of Birth (mm/dd/yyyy).

Under Immigration Status, check one: I am a U.S. citizen. I am a U.S. national. I am a lawful permanent resident.

To be completed by petitioner sponsors only: check Yes or No for I am currently on active duty in the United States Armed Forces or U.S. Coast Guard.

Enter the Principal Immigrant's Full Legal Name. Do not provide a nickname.

Enter the Current Mailing Address, with the In Care Of Name (if any).

Enter the Country of Citizenship or Nationality and the Date of Birth (mm/dd/yyyy).

Enter the Alien Registration Number (A-Number) (if any) and USCIS Online Account Number (if any).

Enter the Daytime Telephone Number.

Check Yes if I am sponsoring the principal immigrant named in Part 3.

Check No, I am sponsoring family members in Part 4. as the second joint sponsor or I am sponsoring family members who are immigrating more than six months after the principal immigrant.

If you need additional space, use the space provided in Part 11. Additional Information.

Persons you are sponsoring in this affidavit: enter the total number of immigrants you are sponsoring on this affidavit which includes the principal immigrant listed in Part 3., any immigrants listed in Part 4., Item Numbers 4. - 7. and, any additional sponsored immigrants you listed in Part 11.

Persons NOT sponsored in this affidavit: do not count any member of your household more than once.

If you are currently married, enter "1" for your spouse. Enter "0" if you already counted your spouse in Item Number 1.

If you have dependent children, enter the number here. Enter "0" if you already counted your dependent children in Item Number 1.

Add together Part 5., Item Numbers 1. - 7. and enter the number here as the Household Size.

Under I am currently:, check Employed as a/an and enter the Name of Employer 1 and the Name of Employer 2 (if applicable).

Or check Self-Employed as a/an (Occupation).

Or check Retired Since (mm/dd/yyyy).

Or check Unemployed Since (mm/dd/yyyy).

Enter My current individual annual income.

Enter My Current Annual Household Income: total all lines from Part 6. Item Numbers 7. - 11.; the total will be compared to Federal Poverty Guidelines on Form I-864P.

Check Yes or No.

Type or print the most recent tax year and your total income for that most recent tax year. If the amount was zero, type or print "zero" or if you were not required to file a Federal income tax return type or print "N/A" for not applicable.

Use of Assets to Supplement Income (if Applicable): if your income, or the total income for you and your household, from Part 6., Item Numbers 12. or 16. exceeds the Federal Poverty Guidelines for your household size, YOU ARE NOT REQUIRED to complete this Part 7. Skip to Part 8.

Sponsor's Statement: check the box for either Item A. or B. in Item Number 1. If applicable, check the box for Item Number 2.

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.

B. The interpreter named in Part 9. 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 10. prepared this affidavit for me based only upon information I provided or authorized.

Sponsor's Contact Information: enter the Sponsor's Daytime Telephone Number, Mobile Telephone Number (if any) and Email Address (if any).

Sponsor's Declaration and Certification: by signing you 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.

Part 11. Additional Information: if you need extra space to provide any additional information within this contract, use the space provided here.

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.

NOTE: As a sponsor, you must include proof of your U.S. citizenship, U.S. national status, or lawful permanent resident status. NOTE: You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year and complete Item Number 16.a.

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.

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