Page 3-5,
Part 6. Sponsor’s
Contract, Statement, Contact Information, Declaration,
Certification, and Signature
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[Page 3]
Part 6. Sponsor's Contract,
Statement, Contact Information, Declaration, 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 person (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.
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 and assets available for the support of the
intending immigrant.
What If I Choose Not to Sign
Form I-864EZ?
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.
What Does Signing Form I-864EZ
Require Me to Do?
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, 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 or U.S. Coast Guard and the person 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.
[Page 4]
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 and assets may be considered
available to that person, 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
and assets as available to the person
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 programs
under the Elementary and Secondary Education Act.
What If I Do Not Fulfill My
Obligations?
If you do not provide sufficient
support to the person who becomes a lawful permanent resident
based on the Form I-864EZ that you signed, that person may sue you
for this support.
If a Federal, state, local, or a
private agency provides any covered means-tested public benefit to
the person who becomes a lawful permanent resident based on the
Form I-864EZ that you signed, the agency may ask you to reimburse
them 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 are sued, and the court
enters a judgment against you, the person 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 person 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. No longer has lawful
permanent resident status and has departed the United States;
D. Becomes 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.
NOTE: Divorce does not
terminate your obligations under this Form I-864EZ.
Your obligations under Form I-864EZ
also end if you die. Therefore, if you die, your estate will not
be required to take responsibility for the person's support after
your death. Your estate may, however, be responsible for any
support that you owed before you died.
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 7. read to me every question and instruction
on this affidavit and my answer to every question in [fillable
box], a language in which I am fluent, and I understood
everything.
2. [ ] At my request, the
preparer named in Part 8., [Fillable Filed], 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 Declaration and
Certification
Copies of any documents I have
submitted are exact photocopies of unaltered, original documents,
and I understand that USCIS or the U.S. Department of State (DOS)
may require that I submit original documents to USCIS or 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 the immigration benefit I seek.
[Page 5]
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 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.
A. I know the contents of
this affidavit of support that I signed;
B. I have read and I
understand each of the obligations described in Part 6.,
and I agree, freely and without any mental reservation or purpose
of evasion, to accept each of those obligations in order to make
it possible for the immigrant indicated in Part 2. to
become a lawful permanent resident of the United States;
C. I agree to submit to the
personal jurisdiction of any Federal or state court that has
subject matter jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864EZ;
D. 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;
E. 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; and
F. I authorize the Social
Security Administration to release information about me in its
records to USCIS and DOS.
Sponsor's Signature
6.a. Sponsor's Signature
6.b. Date of Signature
(mm/dd/yyyy)
[New]
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 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.
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.
What If I Choose Not to Sign Form
I-864EZ?
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.
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.
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.
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.
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.
[deleted]
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.
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 [fillable box], a language in
which I am fluent, and I understood everything.
2. [ ] At my request, the
preparer named in Part 9.,
[Fillable Filed], 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:
[deleted]
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;
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;
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;
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.
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.
Sponsor's Signature
6.a. Sponsor's Signature
6.b. Date of Signature
(mm/dd/yyyy)
Subscribed and
sworn to (or affirmed) before me this [fillable field] day of
[fillable field] (month), [fillable field] (year) at [fillable
field].
My commission
expires on (mm/dd/yyyy) __________.
Signature of Notary Public
Notary
Public Stamp
[space
for stamp]
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.
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Page 6,
Part 8. Contact
Information, Declaration, and Signature of the Person Preparing
this Affidavit, if Other Than the Sponsor
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[Page 6]
Part 8. Contact
Information, Declaration, and Signature of the
Person Preparing this Affidavit, if Other Than the Sponsor
Provide the following
information about the preparer.
Preparer's Full Name
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)
Preparer's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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)
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.
NOTE: If you are an attorney
or accredited representative, you may be obliged 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
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
Declaration and 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.
|
Part 9.
Contact Information, Certification,
and Signature of the Person Preparing this Affidavit, if Other
Than the Sponsor
Provide the following
information about the preparer.
Preparer's Full Name
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)
Preparer's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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)
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.
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
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)
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