Form I-864EZ Affiavit of Support of Support Under Section 213A of the

Affidavit of Support Under Section 213A of the INA

USCIS
Form I-864EZ

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0075
Expires 10/31/2021

For Government Use Only
Adjusted Household Size
This Form I-864EZ:

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DOES NOT MEET
the requirements of
INA section 213A

MEETS the
requirements of
INA section 213A

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 or
G-28I is attached.

Reviewed By:
Location:

Date (mm/dd/yyyy):

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Qualifying to Use Form I-864EZ

Mailing Address

1.a. I am the petitioner of the family member sponsored on
this affidavit.
Yes
No (Use Form I-864)

2.a. In Care Of Name (if any)

1.b. I am using my own earned or retirement income, which is
documented using Internal Revenue Service (IRS) Form
W-2.
Yes
No (Use Form I-864)

2.b. Street Number and Name

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

2.c.

Apt.

(USPS ZIP Code Lookup)

Ste.

Flr.

2.d. City or Town

No (Use Form I-864)

2.e. State

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

2.f.

ZIP Code

2.g. Province

2.h. Postal Code

Name of Immigrant
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Form I-864EZ 10/15/19

2.i.

Country

Other Information
3.

Daytime Telephone Number

4.

Date of Birth (mm/dd/yyyy)

5.

Gender

6.

Alien Registration Number (A-Number) (if any)
► A-

7.

USCIS Online Account Number (if any)
►

8.

U.S. Social Security Number (if any)
►

Male

Female

Page 1 of 9

Part 3. Information About You (Sponsor)

Other Information

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

5.

Country of Domicile

6.

Date of Birth (mm/dd/yyyy)

7.

City or Town of Birth

1.c. Middle Name

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Mailing Address

2.a. In Care Of Name (if any)

2.b. Street Number and Name

2.c.

Apt.

Ste.

2.g. Province

2.f.

3.

Country

9.

Country of Birth

10.

U.S. Social Security Number (Required)
►

11.

USCIS Online Account Number (if any)
►

ZIP Code

Citizenship or Nationality

2.h. Postal Code
2.i.

State or Province of Birth (if applicable)

Flr.

2.d. City or Town
2.e. State

8.

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.

12.

I am a U.S. citizen.

13.a.

I am a lawful permanent resident.

13.b. My alien registration number is:
► A14.

Military Service

15.

Physical Address

I am a U.S. national.

I am currently on active duty in the United States Armed
Forces, other than for active duty training.

4.a. Street Number and Name

Yes

No

Sponsor's Bank Account Information
4.b.

Apt.

Ste.

Flr.

16.a. Account Type

4.c. City or Town
4.d. State
4.f.

Sponsor's Bank Account Information

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

Form I-864EZ 10/15/19

Checking

Savings

16.b. Account Holder's Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name

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Part 3. Information About You (Sponsor)
(continued)

2.

16.c. Name(s) of Joint Account Holders, if any
Family Name
(Last Name)
Given Name
(First Name)

If you answered “Yes” to Item Number 1., enter the total
number of individuals for whom you previously
submitted Form I-864 or Form I-864EZ. You need not
include any individual for whom your sponsorship
obligation has ended, that is, if you know that: 1) the
individual became a United States citizen, 2) the
individual is currently a lawful permanent resident that
has worked or can be credited with 40 qualifying quarters
of coverage, 3) the individual abandoned or lost his or her
lawful permanent resident status, 4) the individual is
deceased, or 5) the individual is obtaining a new grant of
adjustment of status while in removal proceedings based
on a new affidavit of support, if one is required. ►

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Middle Name

16.d. Institution Name

16.e. Account Number

16.f. Routing Number

Provide the following information for each individual for whom
you previously submitted Form I-864 or Form I-864EZ. If you
need more space to provide the information, use Part 10.
Additional Information.
3.a. Sponsored Individual's Name

Part 4. Information About Your Household Size
NOTE: Do not count any household member more than once.

3.b. Date of Birth (mm/dd/yyyy)

3.c. Alien Registration Number (A-Number) (if any)

1.a. You and the individual you are sponsoring on this Form
I-864EZ.
1.b. Your spouse.

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

1.d. If you have sponsored any other persons on a Form I-864
who are now lawful permanent residents in the United
States and for whom your support obligation has not
ended, 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 Part 4., Item Numbers 1.a. - 1.e. and enter
the number here. This is your household size for the
purpose of this Form I-864EZ.
Household Size:

► A-

Part 6. 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

Part 5. Previously Submitted Affidavits of
Support

3.b. Date of Retirement (mm/dd/yyyy)

1.

4.

Have you submitted Form I-864 or Form I-864EZ for any
individuals other than those named on this form?
Yes
No

Form I-864EZ 10/15/19

My current individual annual income $

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Federal Income Tax Information

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 available for the support of the intending immigrant.

5.a. Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No

What If I Choose Not to Sign Form I-864EZ?

Part 6. Information About Your Employment
and Income (continued)

NOTE: You MUST attach a photocopy or transcript
of your Federal income tax return for only the most
recent tax year.
5.b.

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.

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(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 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

$

What Does Signing Form I-864EZ Require Me to
Do?

If an intending immigrant becomes a lawful permanent resident
of 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 other than
active duty for training and the individual 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.

Credit Report Information (Optional)
7.

I have attached a copy of a recent U.S. credit report.

Part 7. Sponsor's Contract, Statement, Contact
Information, 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 individual
(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.

Form I-864EZ 10/15/19

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 may be considered available to that
individual, 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 as
available to the individual.
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 public benefits
programs under the Elementary and Secondary Education Act.

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Part 7. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
What If I Do Not Fulfill My Obligations?
If you do not provide sufficient support to the individual who
becomes a lawful permanent resident based on the Form I-864EZ
that you signed, that individual may sue you for this support.

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 8. read to me every
question and instruction on this affidavit and my
answer to every question in

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If a Federal, state, local, or a private agency provides any covered
means-tested public benefit to the individual who becomes a
lawful permanent resident based on the Form I-864EZ that you
signed, you are responsible for reimbursing the agency 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 fail to reimburse the benefit
granting agency upon request, you may be found ineligible to be
a sponsor in the future.
If you are sued, and the court enters a judgment against you, the
individual 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 individual
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.

Has abandoned or lost lawful permanent resident status
and has departed the United States;

D.

Is 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.

Your obligations under this Form I-864EZ also end if you die.
Therefore, if you die, your estate will not be required to take
responsibility for the individual's support after your death.
However, your estate may be required to reimburse a public
benefit-granting agency for any means-tested public benefits
that the intending immigrant received before you died.
NOTE: Divorce does not terminate your obligations under this
Form I-864EZ.
Form I-864EZ 10/15/19

,

a language in which I am fluent, and I understood
everything.

2.

At my request, the preparer named in Part 9.,
,

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 Certification

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that I may be required to submit original documents to USCIS
or the U.S Department of State (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 any benefit I seek.
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:
A.

I provided or authorized to have provided all of the
information in my affidavit, I understand all of the
information contained in, and submitted with, my
affidavit, and that all of this information is complete,
true, and correct;

B.

I am willing and able to receive, maintain, and
provide support to the individual named in Part 2. at
the applicable threshold set forth in the Poverty
Guidelines and by statute;

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Part 7. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
C.

I understand that during the duration of my
obligation as a sponsor, I may be sued if the
individuals named in Part 2. receive means-tested
public benefits after admission to the United States;

D.

I understand that Form I-864EZ may be made
available to any Federal, State, or local agency that
may receive an application from the individuals
named in Part 2. for Supplemental Nutrition
Assistance Program (SNAP) benefits (formerly
called Food Stamps), Medicaid (other than
Emergency Medicaid), Supplemental Security
Income, Temporary Assistance to Needy Families,
or other means-tested public benefits;

E.

I understand that if the individual named in Part 2.
does apply for SNAP/Food Stamps, Supplemental
Security Income, Medicaid (other than Emergency
Medicaid) or Temporary Assistance for Needy
Families or other means-tested public benefits, my
own income may be considered in deciding the
individual's application. How long my income and
may be attributed to the individuals named in Part
3. is determined under the statutes and rules
governing each specific program;

K.

I authorize agencies and entities that administer or
oversee means-tested public benefits, and any
agency or entity that is authorized to act on its
behalf, to disclose information to the Department of
Homeland Security (DHS) and Department of State
(DOS), for the purpose of administration of federal
laws regarding my obligations as a sponsor, as
agreed to in this affidavit and only as permitted by
law. If any alien that I sponsor on this affidavit
applies for a means-tested public benefit, including
Medicaid, the Children's Health Insurance Program,
Temporary Assistance to Needy Families, or the
Supplemental Nutrition Assistance Program, or any
other Federal or State public benefit subject to
deeming of my income and/or assets/resources or for
which I could be liable for reimbursement, I
specifically authorize the agencies and entities that
administer or oversee means-tested public benefits,
and any agency or entity that is authorized to act on
its behalf, to disclose my name, Social Security
number, date of birth, information about the
agency's deeming of my income and/or assets/
resources, and any reimbursement obligations to
DHS and DOS. This consent is valid for the entire
period of enforceability of my obligations as a
sponsor.

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F.

I agree to submit to the personal jurisdiction of any
Federal state, or local court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864EZ;

G.

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;

H.

I understand that, if I am related to the sponsored
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;

I.

I understand that if I fail to respond within 45 days
to a request for reimbursement from a public
benefit-granting agency or an appropriate
government entity because the individual named in
Part 2. received a means tested public benefit, an
action may be brought against me pursuant to the
affidavit of support;

J.

I understand that I may be subject to a civil penalty
if I fail to notify U.S. Citizenship and Immigration
Services (USCIS) of any change in my address,
within 30 days of the change, by filing Form I-865,
Sponsor's Notice of Change of Address;

Form I-864EZ 10/15/19

I understand that the information that agencies and
entities that administer or oversee means-tested
public benefits, and any agency or entity that is
authorized to act on its behalf, disclose to DHS and
DOS is for official use only to administer federal
laws regarding my support obligations as a sponsor,
and that DHS and
DOS may disclose my information only as
authorized by law;

L.

I authorize the Social Security Administration (SSA)
to disclose information to DHS and DOS, for the
purpose of administration of federal laws regarding
my obligations as a sponsor, as agreed to in this
affidavit and only as permitted by law. If any alien
that I sponsor on this affidavit applies for
Supplemental Security Income payments, I
specifically authorize SSA to disclose my name,
Social Security number, date of birth, the deeming
of my income and/or assets/resources, and my
reimbursement obligations to DHS and
DOS. This consent is valid for the entire period of
enforceability of my obligations as a sponsor. I
understand that the information SSA discloses to
DHS and DOS is for official use for the purpose of
administration of federal laws regarding my
obligation as a sponsor and that DHS and DOS may
disclose my information as authorized by law; and

M. I acknowledge that if I fail to meet the obligations of
sponsorship, I may be found ineligible to be a
sponsor in the future.
Page 6 of 9

Interpreter's Mailing Address

Part 7. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)

3.a. Street Number and Name

Sponsor's Signature

3.b.

6.a. Sponsor's Signature

3.c. City or Town

Apt.

Ste.

Flr.

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3.d. State

3.e. ZIP Code

6.b. Date of Signature (mm/dd/yyyy)

3.f.

Subscribed and sworn to (or affirmed) before me this

3.g. Postal Code

day of

(Month),

(Year) at

My commission expires on (mm/dd/yyyy)

Signature of Notary Public

Notary Public Stamp

Province

3.h. Country

,

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

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.

Part 8. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

,

which is the same language specified in Part 7., 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 Certification, and has
verified the accuracy of every answer.

Interpreter's Signature
7.a. Interpreter's Signature

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

7.b. Date of Signature (mm/dd/yyyy)

1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Form I-864EZ 10/15/19

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Part 9. Contact Information, Certification, and
Signature of the Person Preparing this Affidavit,
if Other Than the Sponsor

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.

Provide the following information about the preparer.

Preparer's Full Name

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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)

NOTE: If you are an attorney or accredited representative,
you may need 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

Preparer's Mailing Address
3.a. Street Number and Name

3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Province

3.e. ZIP Code

3.g. Postal Code
3.h. Country

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 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)

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Form I-864EZ 10/15/19

Page 8 of 9

5.a. Page Number

Part 10. 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.

5.b. Part Number

5.c. Item Number

5.d.

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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.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-864EZ 10/15/19

4.c. Item Number

7.a. Page Number

7.d.

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