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Affidavit of Support Under Section 213A of the Act (United States)

This form is to ensure an immigrant has adequate means of financial support in the United States. The form provided here is simply a sample of what the actual Form I-864 looks like.

U.S. Department of Justice
Immigration and Naturalization Service

Affidavit of Support Under Section 213A of the Act

FOR AGENCY USE ONLY

This Affidavit Receipt

[___] Meets [___] Does not meet Requirements of Section 213A

__________________________________ Officer or I.J. Signature

__________________________________ Location

__________________________________ Date

Receipt __________________________________


START HERE - Please Type or Print

Part 1. Information on Sponsor (You)

Last Name __________________________________

First Name __________________________________

Middle Name __________________________________

Mailing Address (Street Number and Name) __________________________________

Apt/Suite Number __________________________________

City __________________________________

State or Province __________________________________

Country __________________________________

ZIP/Postal Code __________________________________

Telephone Number __________________________________

Place of Residence if different from above (Street Number and Name) __________________________________

Apt/Suite Number __________________________________

City __________________________________

State or Province __________________________________

Country __________________________________

ZIP/Postal Code __________________________________

Telephone Number __________________________________

Date of Birth (Month, Day, Year) __________________________________

Place of Birth (City, State, Country) __________________________________

Are you a U.S. Citizen? ____ Yes ____ No

Social Security Number __________________________________

A-Number (If any) __________________________________

Part 2. Basis for Filing Affidavit of Support

I am filing this affidavit of support because (check one):

a. ____ I filed/am filing the alien relative petition.

b. ____ I filed/am filing an alien worker petition on behalf of the intending immigrant, who is related to me as my __________________________________ (relationship)

c. ____ I have ownership interest of at least 5% __________________________________ (name of entity which filed visa petition) which filed an alien worker petition on behalf of the intending immigrant, who is related to me as my __________________________________ (relationship)

d. ____ I am a joint sponsor willing to accept the legal obligations with any other sponsor(s).

Part 3. Information on the Immigrant(s) You Are Sponsoring

Last Name __________________________________

First Name __________________________________

Middle Name __________________________________

Date of Birth (Month, Day, Year) __________________________________

Sex ____ Male ____ Female

Social Security Number (If any) __________________________________

Country of Citizenship A-Number (If any) __________________________________

Current Address (Street Number and Name) __________________________________

Apt/Suite Number __________________________________

City __________________________________

State/Province __________________________________

Country __________________________________

ZIP/Postal Code __________________________________

Telephone Number __________________________________

List any spouse and/or children immigrating with the immigrant named above in this Part: (Use additional sheet of paper if necessary.)

Name __________________________________

Relationship to Sponsored Immigrant ____ Spouse ____ Son ____ Daughter

Date of Birth (mo/day/year) __________________________________

A-Number (if any) __________________________________

Social Security (if any) __________________________________

Name __________________________________

Relationship to Sponsored Immigrant ____ Spouse ____ Son ____ Daughter

Date of Birth (mo/day/year) __________________________________

A-Number (if any) __________________________________

Social Security (if any) __________________________________


Name __________________________________

Relationship to Sponsored Immigrant ____ Spouse ____ Son ____ Daughter

Date of Birth (mo/day/year) __________________________________

A-Number (if any) __________________________________

Social Security (if any) __________________________________

Part 4. Eligibility to Sponsor

To be a sponsor you must be a U.S. citizen or national or a lawful permanent resident. If you are not the petitioning relative, you must provide proof of status. To prove status, U.S. citizens or nationals must attach a copy of a document proving status, such as a U.S. passport, birth certificate, or certificate of naturalization, and lawful permanent residents must attach a copy of both sides of their Permanent Resident Card (Form I-551).

The determination of your eligibility to sponsor an immigrant will be based on an evaluation of your demonstrated ability to maintain an annual income at or above 125 percent of the Federal poverty line (100 percent if you are a petitioner sponsoring your spouse or child and you are on active duty in the U.S. Armed Forces). The assessment of your ability to maintain an adequate income will include your current employment, household size, and household income as shown on the Federal income tax returns for the 3 most recent tax years. Assets that are readily converted to cash and that can be made available for the support of sponsored immigrants if necessary, including any such assets of the immigrant(s) you are sponsoring, may also be considered.

The greatest weight in determining eligibility will be placed on current employment and household income. If a petitioner is unable to demonstrate ability to meet the stated income and asset requirements, a joint sponsor who can meet the income and asset requirements is needed. Failure to provide adequate evidence of income and/or assets or an affidavit of support completed by a joint sponsor will result in denial of the immigrant's application for an immigrant visa or adjustment to permanent resident status.

A. Sponsor's Employment

I am:

1. ____ Employed by __________________________________ (Provide evidence of employment)

Annual salary or hourly wage $_______________ (for __________ hours per week)

2. ____ Self employed __________________________________ (Name of business)

Nature of employment or business __________________________________

3. ____ Unemployed or retired since __________________________________

B. Sponsor's Household Size Number

1. Number of persons (related to you by birth, marriage, or adoption) living in your residence, including yourself (Do NOT include persons being sponsored in this affidavit.)......_______________

2. Number of immigrants being sponsored in this affidavit (Include all persons in Part 3. .)......_______________

3. Number of immigrants NOT living in your household whom you are obligated to support under a previously signed Form I-864......_______________

4. Number of persons who are otherwise dependent on you, as claimed in your tax return for the most recent tax year......_______________

5. Total household size. (Add lines 1 through 4.) Total......_______________

List persons below who are included in lines 1 or 3 for whom you previously have submitted INS Form I-864, if your support obligation has not terminated.

(If additional space is needed, use additional paper)

Name __________________________________

A-Number __________________________________

Date Affidavit of Support Signed __________________________________

Relationship __________________________________


Name __________________________________

A-Number __________________________________

Date Affidavit of Support Signed __________________________________

Relationship __________________________________

Name __________________________________

A-Number __________________________________

Date Affidavit of Support Signed __________________________________

Relationship __________________________________

C. Sponsor's Annual Household Income

Enter total unadjusted income from your Federal income tax return for the most recent tax year below. If you last filed a joint income tax return but are using only your own income to qualify, list total earnings from your W-2 Forms, or, if necessary to reach the required income for your household size, include income from other sources listed on your tax return. If your individual income does not meet the income requirement for your household size, you may also list total income for anyone related to you by birth, marriage, or adoption currently living with you in your residence if they have lived in your residence for the previous 6 months, or any person shown as a dependent on your Federal income tax return for the most recent tax year, even if not living in the household. For their income to be considered, household members or dependents must be willing to make their income available for support of the sponsored immigrant(s) and to complete and sign Form I-864A, Contract Between Sponsor and Household Member. A sponsored immigrant/household member only need complete Form I-864A if his or her income will be used to determine your ability to support a spouse and/or children immigrating with him or her.

You must attach evidence of current employment and copies of income tax returns as filed with the IRS for the most recent 3 tax years for yourself and all persons whose income is listed below. See ''Required Evidence '' in Instructions. Income from all 3 years will be considered in determining your ability to support the immigrant(s) you are sponsoring.

____ I filed a single/separate tax return for the most recent tax year.

____ I filed a joint return for the most recent tax year which includes only my own income.

____ I filed a joint return for the most recent tax year which includes income for my spouse and myself.

____ I am submitting documentation of my individual income (Forms W-2 and 1099).

____ I am qualifying using my spouse's income; my spouse is submitting a Form I-864A.

Indicate most recent tax year __________ (tax year)

Sponsor's individual income $_______________

or

Sponsor and spouse's combined income (If spouse's income is to be considered, spouse must submit Form I-864A.) $_______________

Income of other qualifying persons. (List names; include spouse if applicable. Each person must complete Form I-864A.)

__________________________ $_______________

__________________________ $_______________

__________________________ $_______________

Total Household Income $_______________

Explain on separate sheet of paper if you or any of the above listed individuals were not required to file Federal income tax returns for the most recent 3 years, or if other explanation of income, employment, or evidence is necessary.

D. Determination of Eligibility Based on Income

1. ____ I am subject to the 125 percent of poverty line requirement for sponsors.

____ I am subject to the 100 percent of poverty line requirement for sponsors on active duty in the U.S. Armed Forces sponsoring their spouse or child.

2. Sponsor's total household size, from Part 4.B., line 5 __________________.

3. Minimum income requirement from the Poverty Guidelines chart for the year of __________ (year) is $____________________ for this household size.

If you are currently employed and your household income for your household size is equal to or greater than the applicable poverty line requirement (from line D.3.), you do not need to list assets (Parts 4.E. and 5) or have a joint sponsor (Part 6) unless you are requested to do so by a Consular or Immigration Officer. You may skip to Part 7, Use of the Affidavit of Support to Overcome Public Charge Ground of Admissibility. Otherwise, you should continue with Part 4.E.

E. Sponsor's Assets and Liabilities

Your assets and those of your qualifying household members and dependents may be used to demonstrate ability to maintain an income at or above 125 percent (or 100 percent, if applicable) of the poverty line if they are available for the support of the sponsored immigrant(s) and can readily be converted into cash within 1 year. The household member, other than the immigrant(s) you are sponsoring, must complete and sign Form I-864A, Contract Between Sponsor and Household Member. List the cash value of each asset after any debts or liens are subtracted. Supporting evidence must be attached to establish location, ownership, date of acquisition, and value of each asset listed, including any liens and liabilities related to each asset listed. See ''Evidence of Assets'' in Instructions.

Type of Asset: Savings deposits
Cash Value of Assets (Subtract any debts) $_______________

Type of Asset: Stocks, bonds, certificates of deposit
Cash Value of Assets (Subtract any debts) $_______________

Type of Asset: Life insurance cash value
Cash Value of Assets (Subtract any debts) $_______________

Type of Asset: Real estate
Cash Value of Assets (Subtract any debts) $_______________

Type of Asset: Other (specify)
Cash Value of Assets (Subtract any debts) $_______________

Total Cash Value of Assets $_______________

Part 5. Immigrant's Assets and Offsetting Liabilities

The sponsored immigrant's assets may also be used in support of your ability to maintain income at or above 125 percent of the poverty line if the assets are or will be available in the United States for the support of the sponsored immigrant(s) and can readily be converted into cash within 1 year.

The sponsored immigrant should provide information on his or her assets in a format similar to part 4.E. above. Supporting evidence must be attached to establish location, ownership, and value of each asset listed, including any liens and liabilities for each asset listed. See ''Evidence of Assets'' in Instructions.

Part 6. Joint Sponsors

If household income and assets do not meet the appropriate poverty line for your household size, a joint sponsor is required. There may be more than one joint sponsor, but each joint sponsor must individually meet the 125 percent of poverty line requirement based on his or her household income and/or assets, including any assets of the sponsored immigrant. By submitting a separate Affidavit of Support under Section 213A of the Act (Form I-864), a joint sponsor accepts joint responsibility with the petitioner for the sponsored immigrant(s) until they become U.S. citizens, can be credited with 40 quarters of work, leave the United States permanently, or die.

Part 7. Use of the Affidavit of Support to Overcome Public Charge Ground of Inadmissibility

Section 212(a)(4)(C) of the Immigration and Nationality Act provides that an alien seeking permanent residence as an immediate relative (including an orphan), as a family-sponsored immigrant, or as an alien who will accompany or follow to join another alien is considered to be likely to become a public charge and is inadmissible to the United States unless a sponsor submits a legally enforceable affidavit of support on behalf of the alien. Section 212(a)(4)(D) imposes the same requirement on an employment-based immigrant, and those aliens who accompany or follow to join the employment- based immigrant, if the employment-based immigrant will be employed by a relative, or by a firm in which a relative owns a significant interest. Separate affidavits of support are required for family members at the time they immigrate if they are not included on this affidavit of support or do not apply for an immigrant visa or adjustment of status within 6 months of the date this affidavit of support is originally signed. The sponsor must provide the sponsored immigrant(s) whatever support is necessary to maintain them at an income that is at least 125 percent of the Federal poverty guidelines.

I submit this affidavit of support in consideration of the sponsored immigrant(s) not being found inadmissible to the United States under section 212(a)(4)(C) (or 212(a)(4)(D) for an employment-based immigrant) and to enable the sponsored immigrant(s) to overcome this ground of inadmissibility. I agree to provide the sponsored immigrant(s) whatever support is necessary to maintain the sponsored immigrant(s) at an income that is at least 125 percent of the Federal poverty guidelines. I understand that my obligation will continue until my death or the sponsored immigrant(s) have become U.S. citizens, can be credited with 40 quarters of work, depart the United States permanently, or die.

Notice of Change of Address.

Sponsors are required to provide written notice of any change of address within 30 days of the change in address until the sponsored immigrant(s) have become U.S. citizens, can be credited with 40 quarters of work, depart the United States permanently, or die. To comply with this requirement, the sponsor must complete INS Form I-865. Failure to give this notice may subject the sponsor to the civil penalty established under section 213A(d)(2) which ranges from $250 to $2,000, unless the failure to report occurred with the knowledge that the sponsored immigrant(s) had received means-tested public benefits, in which case the penalty ranges from $2,000 to $5,000.

If my address changes for any reason before my obligations under this affidavit of support terminate, I will complete and file INS Form I-865, Sponsor's Notice of Change of Address, within 30 days of the change of address. I understand that failure to give this notice may subject me to civil penalties.

Means-tested Public Benefit Prohibitions and Exceptions.

Under section 403(a) of Public Law 104-193 (Welfare Reform Act), aliens lawfully admitted for permanent residence in the United States, with certain exceptions, are ineligible for most Federally-funded means-tested public benefits during their first 5 years in the United States. This provision does not apply to public benefits specified in section 403(c) of the Welfare Reform Act or to State public benefits, including 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; student assistance under the Higher Education Act and the Public Health Service Act; certain forms of foster-care or adoption assistance under the Social Security Act; Head Start programs; means-tested programs under the Elementary and Secondary Education Act; and Job Training Partnership Act programs.

Consideration of Sponsor's Income in Determining Eligibility for Benefits.

If a permanent resident alien is no longer statutorily barred from a Federally-funded means-tested public benefit program and applies for such a benefit, the income and resources of the sponsor and the sponsor's spouse will be considered (or deemed) to be the income and resources of the sponsored immigrant in determining the immigrant's eligibility for Federal means-tested public benefits. Any State or local government may also choose to consider (or deem) the income and resources of the sponsor and the sponsor's spouse to be the income and resources of the immigrant for the purposes of determining eligibility for their means-tested public benefits. The attribution of the income and resources of the sponsor and the sponsor's spouse to the immigrant will continue until the immigrant becomes a U.S. citizen or has worked or can be credited with 40 qualifying quarters of work, provided that the immigrant or the worker crediting the quarters to the immigrant has not received any Federal means-tested public benefit during any creditable quarter for any period after December 31, 1996.

I understand that, under section 213A of the Immigration and Nationality Act (the Act), as amended, this affidavit of support constitutes a contract between me and the U.S. Government. This contract is designed to protect the United States Government, and State and local government agencies or private entities that provide means-tested public benefits, from having to pay benefits to or on behalf of the sponsored immigrant(s), for as long as I am obligated to support them under this affidavit of support. I understand that the sponsored immigrants, or any Federal, State, local, or private entity that pays any means-tested benefit to or on behalf of the sponsored immigrant(s), are entitled to sue me if I fail to meet my obligations under this affidavit of support, as defined by section 213A and INS regulations.

Civil Action to Enforce.

If the immigrant on whose behalf this affidavit of support is executed receives any Federal, State, or local means-tested public benefit before this obligation terminates, the Federal, State, or local agency or private entity may request reimbursement from the sponsor who signed this affidavit. If the sponsor fails to honor the request for reimbursement, the agency may sue the sponsor in any U.S. District Court or any State court with jurisdiction of civil actions for breach of contract. INS will provide names, addresses, and Social Security account numbers of sponsors to benefit-providing agencies for this purpose. Sponsors may also be liable for paying the costs of collection, including legal fees.

I acknowledge that section 213A(a)(1)(B) of the Act grants the sponsored immigrant(s) and any Federal, State, local, or private agency that pays any means-tested public benefit to or on behalf of the sponsored immigrant(s) standing to sue me for failing to meet my obligations under this affidavit of support. I agree to submit to the personal jurisdiction of any court of the United States or of any State, territory, or possession of the United States if the court has subject matter jurisdiction of a civil lawsuit to enforce this affidavit of support. I agree that no lawsuit to enforce this affidavit of support shall be barred by any statute of limitations that might otherwise apply, so long as the plaintiff initiates the civil lawsuit no later than ten (10) years after the date on which a sponsored immigrant last received any means-tested public benefits.

Collection of Judgment.

I acknowledge that a plaintiff may seek specific performance of my support obligation. Furthermore, any money judgment against me based on this affidavit of support may be collected through the use of a judgment lien under 28 U.S.C 3201, a writ of execution under 28 U.S.C 3203, a judicial installment payment order under 28 U.S.C 3204, garnishment under 28 U.S.C 3205, or through the use of any corresponding remedy under State law. I may also be held liable for costs of collection, including attorney fees.

Concluding Provisions.

I, _______________________________, certify under penalty of perjury under the laws of the United
States that:

(a) I know the contents of this affidavit of support signed by me;
(b) All the statements in this affidavit of support are true and correct,
(c) I make this affidavit of support for the consideration stated in Part 7, freely, and without any mental reservation or purpose of evasion;
(d) Income tax returns submitted in support of this affidavit are true copies of the returns filed with the Internal Revenue Service; and
(e) Any other evidence submitted is true and correct.

_______________________ (Sponsor's Signature)

_______________________ (Date)

Subscribed and sworn to (or affirmed) before me this

____________________ day of _______________________ (Month), __________ (Year)

at ________________________________,

My commission expires on _________________________________.

_______________________ (Signature of Notary Public or Officer Administering Oath)

_______________________ (Title)

Part 8. If someone other than the sponsor prepared this affidavit of support, that person must complete the following:

I certify under penalty of perjury under the laws of the United States that I prepared this affidavit of support at the sponsor's request, and that this affidavit of support is based on all information of which I have knowledge.

Signature _______________________

Print Your Name _______________________

Date _______________________

Daytime Telephone Number _______________________

Firm Name and Address _______________________


Contract Between Sponsor and Household Member

Sponsor's Name (Last, First, Middle) _______________________

Social Security Number _______________________

A-Number (If any) _______________________

General Filing Instruction

Form I-864A, Contract Between Sponsor and Household Member, is an attachment to Form I-864, Affidavit of Support Under Section 213A of the Immigration and Nationality Act (the Act). The sponsor enters the information above, complete Part 2 of this form, and signs in Part 5. The household member completes Parts 1 and 3 of this form and signs in Part 6. A household member who is also the sponsored immigrant completes Parts 1 and 4 (instead of Part 3) of this form and signs i Part 6. The Privacy Act Notice and information on penalties for misrepresentation or fraud are included on the instructions to Form I-864.

The signatures on the I-864A must be notarized by a notary public or signed before an immigration or consular officer. A separate form must be used for each household member whose income and/or assets are being used to qualify. This blank form may be photocopied for that purpose. A sponsored immigrant who qualifies as a household member is only required to complete this form if he or she has one or more family members immigrating with him or her and is making his or her income available for their support. Sponsored immigrants who are using their assets to qualify are not required to complete this form. This completed form is submitted with Form I-864 by the sponsored immigrant with an application for an immigrant visa or adjustment of status.

Purpose

This contract is intended to benefit the sponsored immigrant(s) and any agency of the Federal Government, any agency of a State or local government, or any private entity to which the sponsor has an obligation under the affidavit of support to reimburse for benefits granted to the sponsored immigrant, and these parties will have the right to enforce this contract in an court with appropriate jurisdiction. Under Section 213A of Act, this contract must be completed and signed by the sponsor and any household member, including the sponsor's spouse, whose income is included as household income by a person sponsoring one or more immigrants. The contract must also be completed if a sponsor is relying on the assets of a household member who is not the sponsored immigrant to meet the income requirements. If the sponsored immigrant is a household member immigrating with a spouse or children, and is using his or her income to assist the sponsor in meeting the income requirement, he or she must complete and sign this contract as a ''sponsored immigrant/household member.''

By signing this form, a household member, who is not a sponsored immigrant, agrees to make his or her income and/or assets available to the sponsor to help support the immigrant(s) for whom the sponsor has filed an affidavit of support and to be responsible, along with the sponsor, to pay any debt incurred by the sponsor under the affidavit of support. A sponsored immigrant/household member who signs this contract agrees to make his or her income available to the sponsor to help support any spouse or children immigrating with him or her and to be responsible, along with the sponsor, to pay any debt incurred by the sponsor under the affidavit of support. The obligations of the household member and the sponsored immigrant/household member under this contract terminate when the obligations of the sponsor under the affidavit of support terminate. For additional information see section 213A of the Act, part 213a of title 8 of the Code of Federal Regulations, and Form I-864, Affidavit of Support Under Section 213A of the Act.
Definitions:

1) An ''affidavit of support'' refers to Form I-864, Affidavit of Support Under Section 213A of the Act, which is complete and filed by the sponsor.

2) A ''sponsor'' is a person, either the petitioning relative, the relative with a significant ownership interest in the petitioning entity, or another person accepting joint and several liability with the sponsor, who completes and files the Affidavit of Support under Section 213A of the Act on behalf of a sponsored immigrant.

3) A ''household member'' is any person (a) sharing a residence with the sponsor for at least the last 6 months who is related to the sponsor by birth, marriage, or adoption, or (b) whom the sponsor has lawfully claimed as a dependent on the sponsor's most recent federal income tax return even if that person does not live at the same residence as the sponsor, and whose income and/or assets will be used to demonstrate the sponsor's ability to maintain the sponsored immigrant(s) at an annual income at the level specified in section 213A(f)(1)(E) or 213A(f)(3) of the Act.

4) A ''sponsored immigrant" is a person listed on this form on whose behalf an affidavit of support will be completed and filed.

5) A ''sponsored immigrant/household member'' is a sponsored immigrant who is also a household member.

Part 1. Information on Sponsor's Household Member or Sponsored Immigrant/Household Member

Last Name _______________________

First Name _______________________

Middle Name _______________________

Date of Birth (Month, Day, Year) _______________________

Social Security Number (Mandatory for non-citizens; voluntary for U.S. citizens) _______________________

A-Number (If any) _______________________

Address (Street Number and Name) _______________________

Apt Number _______________________

City _______________________

State/Province _______________________

ZIP/Postal Code _______________________

Telephone Number _______________________

Relationship to Sponsor: _______________________

I am: ____ The sponsor's household member. (Complete Part 3.)

____ The sponsored immigrant/household member. (Complete Part 4.)

Length of residence with sponsor _______________________ (years, months)

Part 2. Sponsor's Promise

I, THE SPONSOR, _______________________ (Print name of sponsor), in consideration of the household member's promise to support the sponsored immigrant(s) and to be jointly and severally liable for any obligations I incur under the affidavit of support, promise to complete and file an affidavit of support on behalf of the following _______________________ (Indicate number) sponsored immigrant(s):

Name of Sponsored Immigrant (First, Middle, Last) _______________________

Date of Birth (Month, Day, Year) _______________________

Social Security Number (If any) _______________________

A-Number (If any) _______________________


Name of Sponsored Immigrant (First, Middle, Last) _______________________

Date of Birth (Month, Day, Year) _______________________

Social Security Number (If any) _______________________

A-Number (If any) _______________________

Name of Sponsored Immigrant (First, Middle, Last) _______________________

Date of Birth (Month, Day, Year) _______________________

Social Security Number (If any) _______________________

A-Number (If any) _______________________

Part 3. Household Member's Promise

I, THE HOUSEHOLD _______________________ (Print name of household member), in consideration of the sponsor's promise to complete and file the affidavit of support on behalf of the sponsored immigrant(s):

1) Promise to provide any and all financial support necessary to assist the sponsor in maintaining the sponsored immigrant(s) at or above the minimum income provided for in section 213A(a)(1)(A) of the Act (not less than 125 percent of the Federal Poverty Guidelines) during the period in which the affidavit of support is enforceable;

2) Agree to be jointly and severally liable for payment of any and all obligations owed by the sponsor under the affidavit of support to the sponsored immigrant(s), to any agency of the Federal Government, to any agency of a state or local government, or to any private entity;

3) Agree to submit to the personal jurisdiction of any court of the United States or of any state, territory, or possession of the United States if the court has subject matter jurisdiction of a civil lawsuit to enforce this contract or the affidavit of support; and

4) Certify under penalty of perjury under the laws of the United States that all the information provided on this form is true and correct to the best of my knowledge and belief and that the income tax returns I submitted in support of the sponsor affidavit are true copies of the returns filed with the Internal Revenue Service.

Part 4. Sponsored Immigrant/Household Member's Promise

I, THE SPONSORED IMMIGRANT/HOUSEHOLD _______________________ (Print name o f sponsored immigrant) in consideration of the sponsor's promise to complete and file the affidavit of support on behalf of the sponsored immigrant(s) accompanying me:

1) Promise to provide any and all financial support necessary to assist the sponsor in maintaining any sponsored immigrant(s) immigrating with me at or above the minimum income provided for in section 213A(a)(1)(A) of the Act (not less than 125 percent of the Federal Poverty Guidelines) during the period in which the affidavit of support is enforceable;

2) Agree to be jointly and severally liable for payment of any and all obligations owed by the sponsor under the affidavit of support to any sponsored immigrant(s) immigrating with me, to any agency of the Federal Government, to any agency of a state or local government, or to any private entity;

3) Agree to submit to the personal jurisdiction of any court of the United States or of any state, territory, or possession of the United States if the court has subject matter jurisdiction of a civil lawsuit to enforce this contract or the affidavit of support; and

4) Certify under penalty of perjury under the laws of the United States that all the information provided on this form is true and correct to the best of my knowledge and belief and that the income tax returns I submitted in support of the sponsor's affidavit of support are true copies of the returns filed with the Internal Revenue Service.

Part 5. Sponsor's Signature

Sponsor's Signature _______________________

Date: _______________________

Subscribed and sworn to (or affirmed) before me this _______________________ day of _______________________ (Month), _______________________ (Year)

at _______________________

My commission expires on _______________________

Signature of Notary Public or Officer Administering Oath _______________________

Title _______________________

Part 6. Household Member's or Sponsored Immigrant/Household Member's Signature

Household Member's or Sponsored Immigrant/Household Member's Signature _______________________

Date: _______________________

Subscribed and sworn to (or affirmed) before me this _______________________ day of _______________________ (Month), _______________________ (Year)

at _______________________

My commission expires on _______________________

Signature of Notary Public or Officer Administering Oath _______________________

Title _______________________

Sponsor's Notice of Change of Address

START HERE - Please Type or Print Answer all Questions

Part 1. Information about Sponsor

Last Name _______________________

First Name _______________________

Middle Name _______________________

Date of Birth (Month, Day, Year) _______________________

Place of Birth (City, State, Country) _______________________

A-Number (If any) _______________________

Social Security Number _______________________

My New Mailing Address (Street Number and Name) _______________________

Apt/Suite Number _______________________

City _______________________

State or Province _______________________

Country _______________________

ZIP/Postal Code _______________________

Telephone Number _______________________

My New Place of Residence if different from above (Street Number and Name) _______________________

Apt/Suite Number _______________________

City _______________________

State or Province _______________________

Country _______________________

IP/Postal Code _______________________

Telephone Number _______________________

Effective Date of Change of Address _______________________

----------------------

FOR AGENCY USE ONLY

Receipt

----------------------

Part 2. Sponsor's Signature

I certify under penalty of perjury under the laws of the United States of America that all information on this notice is true and correct.

Signature _______________________

Date _______________________

Daytime Telephone _______________________

Part 3. Signature of person preparing notice if other than sponsor

I declare I prepared this application at the request of the above person and it is based on information of which I have knowledge.

Signature _______________________

Date _______________________

Daytime Telephone _______________________

Last Name (Print) _______________________

First name _______________________

Middle Initial _______________________

Firm Name and Address (Print) _______________________

Public Reporting Burden

Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. The estimated average time to complete and file this form is 15 minutes. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536, OMB No.1115-0215. DO NOT MAIL THIS FORM TO THIS ADDRESS.

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