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SAMPLE I-864 Form - Affidavit of Support Under Section ...

Affidavit of Support Under Section 213A of the ActDepartment of Homeland Security Citizenship and Immigration ServicesUSCISForm I-864 OMB No. 1615-0075 Expires 03/31/2015 START HERE - Type or print in black ink. form I-864 03/22/13 NPage 1 of 9 Part 1. Basis For Filing Affidavit of Supportam the sponsor submitting this Affidavit of Support because (Check only one box):I am the petitioner. I filed or am filing for the immigration of my filed an alien worker petition on behalf of the intending immigrant, who is related to me as have an ownership interest of at least 5 percent inI am the only joint am theThe original petitioner is deceased.

Affidavit of Support Under Section 213A of the Act Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-864 OMB No. 1615-0075

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Transcription of SAMPLE I-864 Form - Affidavit of Support Under Section ...

1 Affidavit of Support Under Section 213A of the ActDepartment of Homeland Security Citizenship and Immigration ServicesUSCISForm I-864 OMB No. 1615-0075 Expires 03/31/2015 START HERE - Type or print in black ink. form I-864 03/22/13 NPage 1 of 9 Part 1. Basis For Filing Affidavit of Supportam the sponsor submitting this Affidavit of Support because (Check only one box):I am the petitioner. I filed or am filing for the immigration of my filed an alien worker petition on behalf of the intending immigrant, who is related to me as have an ownership interest of at least 5 percent inI am the only joint am theThe original petitioner is deceased.

2 I am the substitute sponsor. I am the intending immigrant'sfirstsecond of two joint filed an alien worker petition on behalf of the intending immigrant, who is related to me as my 2. Information on the Principal Name (Last Name) Name (First Name) Name Mailing or of Citizenship Other Information (mm/dd/yyyy)Date of Birth Code Registration Number (A-Number) Numberand : If you check box , , , , or , you must include proof of your citizen, national, or lawful permanent resident status. of Support SubmitterPetitioner1st Joint Sponsor2nd Joint SponsorForUSCISUseOnlyRemarksDate:Review ed By:Office:Substitute Sponsor5% OwnerSection 213A ReviewMEETS requirementsDOES NOT MEET requirementsMMDDYYYY//Number of Support affidavits in File12 Rahul Ram GuptaAGRAWALM anishaDeviMumbai456 Laurel St4511/24 SAMPLEForm I-864 03/22/13 NPage 2 of 9 Part 3.

3 Information on the Immigrant(s) You Are am sponsoring the principal immigrant named in Part am sponsoring the following family members immigrating at the same time or within 6 months of the principal immigrant named in Part 2. Do notinclude any relative listed on a separate visa (Applicable only in cases with two joint sponsors) Name (First Name) Name (Last Name) Name (Last Name) Name (First Name) to Sponsored Immigrant (mm/dd/yyyy)Date of Birth Registration Number (A-Number) of Birth (mm/dd/yyyy) Relationship to Sponsored Registration Number (A-Number) of Birth (mm/dd/yyyy) Relationship to Sponsored Name (First Name) Name (Last Name) Registration Number (A-Number)Alien Registration Number (A-Number) Name (Last Name) Name (First Name) to Sponsored Immigrant (mm/dd/yyyy)

4 Date of Birth Name (First Name) Name (Last Name) Member 1 Family Member 2 Family Member 3 Family Member 4 Middle Member 5 A- A- A- A-AGRAWALJaySon05/01 SAMPLEPage 3 of 9 form I-864 03/22/13 of Birth (mm/dd/yyyy) Relationship to Sponsored the total number of immigrants you are sponsoring on this form from Items Registration Number (A-Number)Family Member 5 (Continued)Part 4. Information on the Sponsor Sponsor's Full Name (Last Name) Name (First Name) NamePart 3. Information on the Immigrant(s) You Are Sponsoring (continued) Sponsor's Mailing or Code Numberand Sponsor's Place of ResidenceCity or Code Other InformationTelephone Number4.

5 (mm/dd/yyyy)Date of Birth of Numberand ()- Park AvenueEdison123 Park Avenue732 481 3053454512/22/197408837NJ08837 NJUSAUSAU nited SAMPLEPage 4 of 9 form I-864 03/22/13 or Province of BirthCity or Town of of Birth am a am a national (for joint sponsors only). am a lawful permanent resident. Service (To be completed by petitioner sponsors only.)I am currently on active duty in the armed Social Security Number (Required) My alien registration number is:Part 5. Sponsor's Household SizeYour Household Size - DO NOT COUNT ANYONE TWICEP ersons you are sponsoring in this the number you entered on line 7 of Part you have dependent children, enter the number you are currently married, enter "1" for your NOT sponsored in this together lines 1-7 and enter the number Size:OPTIONAL.

6 If you have siblings, parents, or adult children with the same principal residence who are combining their income with yours by submitting form I-864A, enter the number you have sponsored any other persons on an I-864 or I-864 EZ who are now lawful permanent residents, enter the number you have any other dependents, enter the number 6. Sponsor's Income and EmploymentI am as a/anName of Employer #1 (if applicable)Name of Employer #2 (if applicable) as a/anPart 4. Information on the Sponsor (continued) from:Company (mm/dd/yyyy)Date of Retirement A-ForUSCISUseOnlyBudd LakeNJ21000003 Software EngineerStar SAMPLEPage 5 of 9 form I-864 03/22/13 since(mm/dd/yyyy) current individual annual income is:(See Instructions)$Income you are using from any other person who was counted in your household size, including, in certain conditions, the intending immigrant.

7 (See Instructions.) Please indicate name, relationship and $RelationshipCurrent $RelationshipCurrent $RelationshipCurrent IncomeCurrent Income$ $My current Annual Household Income(Total all lines from 5, , , , and Will be Compared to Poverty Guidelines -- See form I-864P.) person(s) listed in , , , and have completed form I-864A. I am filing along with this form all necessary Forms I-864A completed by these person(s) listed in , , , or does not need to complete form I-864A because he/she is the intending immigrant and has no accompanying 6. Sponsor's Income and Employment(continued)Person 1 Person 2 Person 3 Person 4 Name(s)Federal income tax return have filed a Federal tax return for each of the three most recent tax years.

8 I have attached the required photocopy or transcript of my Federal tax return for only the most recent tax year. Household Size14 ForUSCISUseOnlyRemarksYear: 2 0 YYPoverty Line:Other2 Poverty Guideline$35678975, , SAMPLEForm I-864 03/22/13 NPage 6 of 9My total income (adjusted gross income on IRS form 1040EZ) as reported on my Federal tax returns for the most recent 3 years (2nd most recent)$(3rd most recent)$$Tax Year(most recent)Total Income14.(Optional) I have attached photocopies or transcripts of my Federal tax returns for my second and third most recent tax 6. Sponsor's Income and Employment (continued)Part 7.

9 Use of Assets to Supplement Income (optional)1.$ the net cash value of real-estate holdings. (Net means current assessed value minus mortgage debt.)$$If your income, or the total income for you and your household,from Part 6, line 10 exceeds the Federal Poverty Guidelines foryour household size, YOU ARE NOT REQUIRED to completethis Part. Skip to Part assets (Optional)Enter the balance of all savings and checking the net cash value of all stocks, bonds, certificates of deposit, and any other assets not already included in lines 1 or $Add together lines 1-3 and enter the number :$$Assets from form I-864A, line 12d for:Name of RelativeEnter the balance of the sponsored immigrant's savings and checking household member's assets from form I-864A.

10 (Optional) of the principal sponsored immigrant (Optional).The principal sponsored immigrant is the person listed in lines - in Part the current cash value of the sponsored immigrant's stocks, bonds, certificates of deposit, and other assets not included on line 6 or the net cash value of all the sponsored immigrant's real estate holdings. (Net means investment value minus mortgage debt.)$$ together lines 4, , and 9 of Part 7 and enter the number value of together lines 6-8 of Part 7 and enter the numberhere.$$TOTAL:Part 7. Use of Assets to Supplement Income (optional) (continued)Household Size14 ForUSCISUseOnlyRemarksYear: 2 0 YYPoverty Line:Other2 Poverty Guideline$356789 The total value of all assets, line 10, must equal 5 times (3 times for spouses and children of USC's, or 1 time for orphans to be formally adopted in the ) the difference between the poverty guidelines and the sponsor's household income, line 's Household Income (Page 5, Line 10)$20112009 63, , , SAMPLEPage 7 of 9 form I-864 03/22/13 NPart 8.


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