I-864 Affidavit of Support PDF
I-864 Affidavit of Support PDF
Form I-864
Department of Homeland Security OMB No. 1615-0075
U.S. Citizenship and Immigration Services Expires 07/31/2017
Affidavit of Support Submitter Section 213A Review Number of Support Affidavits in File
Petitioner MEETS DOES NOT MEET 1 2
For requirements requirements
USCIS 1st Joint Sponsor
Remarks
Use 2nd Joint Sponsor Reviewed By:
Only Substitute Sponsor Office:
5% Owner Date (mm/dd/yyyy):
Part 1. Basis For Filing Affidavit of Support Part 2. Information About the Principal
Immigrant
I, , 1.a. Family Name
am the sponsor submitting this affidavit of support because (Last Name)
(Select only one box):
1.b. Given Name
1.a. I am the petitioner. I filed or am filing for the (First Name)
immigration of my relative.
1.c. Middle Name
1.b. I filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my
Mailing Address
2.a. In Care Of Name
1.c. I have an ownership interest of at least 5 percent in
which filed an alien worker petition on behalf of the 2.b. Street Number
intending immigrant, who is related to me as my and Name
2.c. Apt. Ste. Flr.
1.d. I am the only joint sponsor. 2.d. City or Town
1.e. I am the first second of two joint sponsors.
2.e. State 2.f. ZIP Code
1.f. The original petitioner is deceased. I am the
substitute sponsor. I am the intending immigrant's 2.g. Province
7. Daytime Telephone Number 11. Alien Registration Number (A-Number) (if any)
A-
22. USCIS ELIS Account Number (if any) 2.e. State 2.f. ZIP Code
2.g. Province
27. USCIS ELIS Account Number (if any) 4.b. Apt. Ste. Flr.
4.c. City or Town
28. Enter the total number of immigrants you are sponsoring
on this affidavit from Item Numbers 1.a. - 27. 4.d. State 4.e. ZIP Code
4.f. Province
I am currently:
1.a. Employed as a/an 5. Current Income $
Person 2
1.a.1. Name of Employer 1 (if applicable) 6. Name
Person 3
1.c. Retired From (Company Name) 9. Name
1.d. Unemployed
11. Current Income $
since (mm/dd/yyyy)
Person 4
2. My current individual annual income is:
12. Name
$
Income you are using from any other person who was 13. Relationship
counted in your household size, including, in certain
conditions, the intending immigrant. (See Form I-864
Instructions.) Please indicate name, relationship, and income. 14. Current Income $
Person 1
15. My Current Annual Household Income (Total all lines
3. Name from Part 6., Item Numbers 2., 5., 8., 11., and 14.; the
total will be compared to Federal Poverty Guidelines on
Form I-864P.) $
16. The people listed in Item Numbers 3., 6., 9., and 12.
have completed Form I-864A. I am filing along with
this affidavit all necessary Form I-864As completed
by these people.
Part 6. Sponsor's Employment and Income Part 7. Use of Assets to Supplement Income
(continued) (Optional)
17. One or more of the people listed in Item Numbers If your income, or the total income for you and your
3., 6., 9., and 12. do not need to complete Form household, from Part 6., Item Numbers 19.a. - 19.c., exceeds
I-864A because he or she is the intending immigrant the Federal Poverty Guidelines for your household size, YOU
and has no accompanying dependents. ARE NOT REQUIRED to complete this Part 7. Skip to
Part 8.
Name
Your Assets (Optional)
1. Enter the balance of all savings and checking accounts.
Federal Income Tax Return Information $
18.a. Have you filed a Federal income tax return for each of the
2. Enter the net cash value of real-estate holdings. (Net
three most recent tax years? Yes No value means current assessed value minus mortgage debt.)
NOTE: You MUST attach a photocopy or transcript of $
your Federal income tax return for only the most recent
3. Enter the net cash value of all stocks, bonds, certificates
tax year.
of deposit, and any other assets not already included in
18.b. (Optional) I have attached photocopies or transcripts Item Number 1. or Item Number 2.
of my Federal income tax returns for my second and $
third most recent tax years.
4. Add together Item Numbers 1. - 3. and enter the
My total income (adjusted gross income on Internal Revenue number here.
Service (IRS) Form 1040EZ) as reported on my Federal income TOTAL: $
tax returns for the most recent three years was:
Assets from Form I-864A, Part 4., Item Number 3.d., for:
Tax Year Total Income
19.a. Most Recent $ 5.a. Name of Relative
Interpreter's Signature
Interpreter's Mailing Address 6.a. Interpreter's Signature
3.a. Street Number
and Name
6.b. Date of Signature (mm/dd/yyyy)
3.b. Apt. Ste. Flr.
5. Interpreter's Email Address (if any) 2. Preparer's Business or Organization Name (if any)
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.
2. A-Number (if any) 5.a. Page Number 5.b. Part Number 5.c. Item Number
A-
5.d.
3.a. Page Number 3.b. Part Number 3.c. Item Number
3.d.