Page 4-5,
Part 6. Sponsor’s
Employment and Income
|
[Page 4]
Part
6. Sponsor's Employment and Income
1.
Employed as
a/an
2.
Name of
Employer 1
3.
Name of Employer 2 (if applicable)
4.
Self-Employed as a/an (Occupation)
5.
Retired Since
(mm/dd/yyyy)
6.
Unemployed Since (mm/dd/yyyy)
7.
My current individual annual income is: $
Income
you are using from any other person who was counted in your
household size, including,
in certain conditions, the intending immigrant. (See Form I-864
Instructions.) Please indicate name, relationship, and income.
Person
1
8.
Name
9.
Relationship
10.
Current Income $
Person
2
11.
Name
12.
Relationship
13.
Current Income $
Person
3
14.
Name
15.
Relationship
16.
Current Income $
Person
4
17.
Name
18.
Relationship
19.
Current Income $
[Page 5]
For
USCIS Use Only
Household
Size
1
2 3 4 5 6 7 8 9 Other
Poverty
Guideline
Year:
20
Poverty
Line: $
Remarks
20.
My Current Annual Household Income (Total
all lines from
Part 6. Item Numbers 7.,
10., 13.,
16.,
and 19.;
the total will be compared to Federal Poverty Guidelines on Form
I-864P.) $
21.
The people
listed in Item
Numbers 8.,
11.,
14., and 17.
have completed Form I-864A. I am filing along with this affidavit
all necessary Form I-864As completed by these people.
22.
One or more of the
people listed in Item
Numbers 8., 11.,
14.,
and 17. do
not need to complete Form I-864A because he or she is the
intending immigrant and has no accompanying dependents.
Name
Federal
Income Tax Return Information
23.a.
Have you filed a Federal income tax return for each of the three
most recent tax years? Yes No
NOTE:
You MUST
attach a
photocopy or transcript of your Federal income tax return for only
the most recent tax year.
23.b.
(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 (adjusted gross income on Internal Revenue Service
(IRS) Form 1040EZ) as reported on my Federal income tax returns
for the most recent three years was:
24.a.
Most Recent Tax Year Total Income $
24.b.
2nd Most Recent
24.c.
3rd Most Recent
25. I was not required to
file a Federal income tax return as my income was below the IRS
required level and I have attached evidence to support this.
[New]
|
Part
7. Sponsor's Employment and Income
1. Employed as a/an
2. Name of Employer 1
3. Name of Employer 2 (if
applicable)
4. Self-Employed as a/an
(Occupation)
5. Retired Since
(mm/dd/yyyy)
6. Unemployed Since
(mm/dd/yyyy)
7. My current individual
annual income is: $
Income you are using from any
other individual who
was counted in your household size, including, in certain
conditions, the intending immigrant. (See Form I-864
Instructions.) Please indicate name, relationship, and income.
Person 1
8. Name
9. Relationship
10. Current Income $
Person 2
11. Name
12. Relationship
13. Current Income $
Person 3
14. Name
15. Relationship
16. Current Income $
Person 4
17. Name
18. Relationship
19. Current Income $
[Page 5]
For USCIS Use Only
Household Size
1 2 3 4 5 6 7 8 9 Other
Poverty Guideline
Year: 20
Poverty Line: $
Remarks
20. My Current Annual Household
Income (Total all lines from Part 7.
Item Numbers 7., 10., 13., 16.,
and 19.; the total will be compared to Federal Poverty
Guidelines on Form I-864P.) $
21. The people listed in
Item Numbers 8., 11., 14., and 17.
have completed Form I-864A. I am filing along with this affidavit
all necessary Form I-864As completed by these people.
22. One or more of the
people listed in Item Numbers 8., 11., 14.,
and 17. do not need to complete Form I-864A because he or
she is the intending immigrant and has no accompanying dependents.
Name
Federal Income Tax Return
Information
23.a. Have you filed a
Federal income tax return for each of the three most recent tax
years? Yes No
NOTE: You MUST attach
a photocopy or transcript of your Federal income tax return for
only the most recent tax year.
23.b. (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:
24.a. Most Recent Tax Year
Total Income $
24.b. 2nd Most Recent
24.c. 3rd Most Recent
25. I was not required to
file a Federal income tax return as my income was below the IRS
required level and I have attached evidence to support this.
Credit
Report Information (Optional)
26.
I have attached a copy of a recent credit report.
|
Page 5-6,
Part 7. Use of
Assets to Supplement Income (Optional)
|
[Page 5]
Part
7. Use of Assets to Supplement Income (Optional)
If
your income, or the total income for you and your household, from
Part 6.,
Item Numbers 20.
or 24.a.
- 24.c., exceeds
the Federal Poverty Guidelines for your household size, YOU
ARE NOT REQUIRED to
complete this Part
7. Skip to Part
8.
Your
Assets (Optional)
1.
Enter the
balance of all savings and checking accounts. $
2.
Enter the net cash value of real-estate holdings. (Net value
means current assessed value minus mortgage debt.) $
3.
Enter the net cash value of all stocks, bonds, certificates of
deposit, and any other assets not already included in Item
Number 1. or
Item Number 2. $
4.
Add together Item
Numbers 1. - 3. and
enter the number here. TOTAL:
$
Assets
from Form I-864A,
Part 4.,
Item Number 3.d.,
for:
5.a.
Name of
Relative
5.b.
Your household
member's assets from Form I-864A (optional). $
Assets
of the principal sponsored immigrant (optional).
The
principal sponsored immigrant is the person listed in Part
2., Item
Numbers 1.a. -
1.c.
Only include the assets if the principal immigrant is being
sponsored by this affidavit of support.
6.
Enter the
balance of the sponsored immigrant's savings and checking
accounts. $
7.
Enter the net cash
value of all the principal immigrant's real estate holdings. (Net
value means investment value minus mortgage debt.) $
8.
Enter the current cash value of the principal immigrant's stocks,
bonds, certificates of deposit, and other assets not included in
Item Number 6. or
Item Number 7. $
[Page 6]
For
USCIS Use Only
Household
Size
1
2 3 4 5 6 7 8 9 Other
Poverty
Guideline
Year:
20
Poverty
Line: $
Sponsor's
Household Income (Page
5, Line 10) $
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 U.S.) the difference between the poverty
guidelines and the sponsor's household income, line 10.
Remarks
9.
Add together Item
Numbers 6. - 8. and
enter the number here. $
Total
Value of Assets
10.
Add together
Item Numbers 4.,
5.b.,
and 9. and
enter the number here. TOTAL:
$
|
Part 8.
Use of Assets to Supplement Income (Optional)
If your income, or the total income
for you and your household, from Part 7.,
Item Numbers 20. or 24.a. - 24.c., exceeds the
Federal Poverty Guidelines for your household size, YOU ARE NOT
REQUIRED to complete this Part 8.
Skip to Part 9.
Your Assets (Optional)
1. Enter the balance of all
savings and checking accounts. $
2. Enter the net cash value
of real-estate holdings. (Net value means current assessed value
minus mortgage debt.) $
3. Enter the net cash value
of all stocks, bonds, certificates of deposit, and any other
assets not already included in Item Number 1. or Item
Number 2. $
4. Add together Item
Numbers 1. - 3. and enter the number here. TOTAL: $
Assets from Form I-864A
(Optional)
If
you need to provide information about more than one Form I-864A,
use the space provided in Part
12. Additional Information.
5.a. Name of household
member
5.b. Your household member's
total assets from Form I-864A,
Part 4.,
Item Number 4.
$
Assets of the principal sponsored
immigrant (Optional)
The principal sponsored immigrant is
the individual listed in Part 2.,
Item Numbers 1.a. - 1.c. Only include the assets if
the principal immigrant is being sponsored by this affidavit of
support.
6. Enter the balance of the
sponsored immigrant's savings and checking accounts. $
7. Enter the net cash value
of all the principal immigrant's real estate holdings. (Net value
means investment value minus mortgage debt.) $
8. Enter the current cash
value of the principal immigrant's stocks, bonds, certificates of
deposit, and other assets not included in Item Number 6. or
Item Number 7. $
[Page 6]
[Deleted]
Household
Size
1 2 3 4 5 6 7 8 9 Other
Poverty Guideline
Year: 20
Poverty Line: $
Sponsor's Household Income (Page
5, Line 10) $
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 U.S.)
the difference between the poverty guidelines and the sponsor's
household income, line 10.
Remarks
9. Add together Item
Numbers 6. - 8. and enter the number here. $
Total Value of Assets
10. Add together Item
Numbers 4., 5.b., and 9. and enter the number
here. TOTAL: $
|
Page 6-8,
Part 8. Sponsor’s
Contract, Statement, Contact Information, Declaration,
Certification, and Signature
|
[Page 6]
Part
8. Sponsor's Contract, Statement, Contact Information,
Declaration, Certification, and Signature
NOTE:
Read the
Penalties section
of the Form I-864 Instructions before completing this part.
Sponsor's
Contract
Please
note that, by signing this Form I-864, 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-864. If you do not understand the
obligations, you may wish to consult an attorney or accredited
representative.
What is the Legal Effect of My
Signing Form I-864?
If you sign Form I-864 on behalf of
any person (called the intending immigrant) who is applying for an
immigrant visa or for adjustment of status to a lawful permanent
resident, and that intending immigrant submits Form I-864 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 person likely
to become a public charge, the U.S. Government can consider your
income and assets as available for the support of the intending
immigrant.
What If I Choose Not to Sign Form
I-864?
The U.S. Government cannot make you
sign Form 1-864 if you do not want to do so. But if you do not
sign Form I-864, the intending immigrant may not become a lawful
permanent resident in the United States.
What Does Signing Form I-864
Require Me To Do?
If an intending immigrant becomes a
lawful permanent resident in the United States based on a Form
I-864 that you have signed, then, until your obligations under
Form I-864 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 (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.
What
Other Consequences Are There?
If
an intending immigrant becomes a lawful permanent resident in the
United States based on a Form I-864 that you have signed, then,
until your obligations under Form I-864 terminate, the U.S.
Government may consider (deem) your income and assets as 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 (deeming) 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 a Form I-864 that you signed,
that person may sue you for this support.
[Page
7]
If
a Federal, state, local, or private agency provided any covered
means-tested public benefit to the person who becomes a lawful
permanent resident based on a Form I-864 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.
When
Will These Obligations End?
Your
obligations under a Form I-864 that you signed will end if the
person who becomes a lawful permanent resident based on that
affidavit:
A. Becomes a U.S. citizen;
B.
Has worked, or can receive credit for, 40 quarters of coverage
under the Social Security Act;
C.
No longer has 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.
NOTE:
Divorce does
not terminate
your obligations under Form I-864.
Your
obligations under a Form I-864 that you signed also end if you
die. Therefore, if you die, your estate is not required to take
responsibility for the person's support after your death. However,
your estate may owe any support that you accumulated 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
9. read to me
every question and instruction on this affidavit and my answer to
every question in
[Language], a language
in which I am fluent, and I understood everything.
2.
At my request, the preparer named in Part
10.,
[Name], 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 and all of my
records that USCIS or DOS may need to determine my eligibility for
the benefit that 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: 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 8.,
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 immigrants indicated in Part
3. to become
lawful permanent residents 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-864;
[Page 8]
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;
[New]
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-864; 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)
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 affidavit.
|
Part 9.
Sponsor's Contract, Statement, Contact Information,
Certification, and Signature
NOTE: Read the Penalties
section of the Form I-864 Instructions before completing this
part.
Sponsor's Contract
Please note that, by signing this
Form I-864, 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-864. If
you do not understand the obligations, you may wish to consult an
attorney or accredited representative.
What is the Legal Effect of My
Signing Form I-864?
If you sign Form I-864 on behalf of
any individual (called the intending
immigrant) who is applying for an immigrant visa or for adjustment
of status to that of a lawful
permanent resident, and that intending immigrant submits Form
I-864 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.
[deleted]
What If
I Choose Not to Sign Form I-864?
The U.S. Government cannot make you
sign Form 1-864 if you do not want to do so. But if you do not
sign Form I-864, the intending immigrant may not become a lawful
permanent resident in the United States.
What Does Signing Form I-864
Require Me To Do?
If an intending immigrant becomes a
lawful permanent resident in the United States based on a Form
I-864 that you have signed, then you must do
all of the following until your
obligations under this Form I-864
terminate:
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 your household size
(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
intending immigrant 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.
What Other Consequences Are
There?
If an intending immigrant becomes a
lawful permanent resident in the United States based on a Form
I-864 that you have signed, then, until your obligations under
Form I-864 terminate, the U.S. Government may consider (deem) your
income and assets as 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 (deeming) of your income and
assets 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 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 a Form I-864
that you signed, that individual may
sue you for this support.
If a Federal, state, local, or
private agency provided any covered means-tested public benefit to
the person who becomes a lawful permanent resident based on this
Form I-864 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.
When Will These Obligations End?
Your obligations under this
Form I-864 will end if the
individual you are sponsoring who
becomes a lawful permanent resident based on the
application for which this affidavit was required:
A. Becomes a U.S. citizen;
B. Has worked, or can
receive credit for, 40 quarters of coverage under the Social
Security Act;
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-864 also end
if you die. Therefore, if you die, your estate is not required to
take responsibility for the individual's
support after
your death. However, your estate may be
required to reimburse a 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 Form I-864.
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 10. read to me
every question and instruction on this affidavit and my answer to
every question in [Language], a language in which I am fluent, and
I understood everything.
2. At my request, the
preparer named in Part 11.,
[Name], 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 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 and all of my records that USCIS or DOS may
need to determine my eligibility for the benefit that 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 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;
[Deleted]
B. I
am willing and able to receive, maintain, and provide support to
the individual named in Part 3. 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
3. receive means-tested benefits
after admission to the United States as immigrants or after being
granted adjustment of status;
D. I
understand that Form I-864 may be made available to any Federal,
State, or local agency that may receive an application from the
individuals named in Part 3.
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 benefits;
E. I
understand that if the individual named in Part
3. does apply for SNAP/Food
Stamps, Supplemental Security Income, Medicaid (other than
Emergency Medicaid) or Temporary Assistance for Needy Families or
other means-tested benefits, my own income and assets may be
considered in deciding the individual’s application. How
long my income and assets may be attributed to the individual
named in Part 3.
is determined under the statutes and rules governing each specific
program;
F. I
have read the section entitled Sponsor
and Beneficiary Liability in the
Instructions for this affidavit, and am aware of my
responsibilities as a sponsor under the Social Security Act, as
amended, and the Food Stamp Act, as amended;
G.
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-864;
H. 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;
I.
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-864;
J. 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
3. received a means-tested
benefit, an action may be brought against me pursuant to the
affidavit of support;
K. 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;
L.
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;
M. 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
N.
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 affidavit.
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Page 9,
Part 10. Contact
Information, Declaration, and Signature of the Person Preparing
this Affidavit, if Other Than the Sponsor
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[Page 9]
Part
10. 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. [Number]
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)
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.
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.
Preparer's
Signature
8.a.
Preparer's
Signature
8.b.
Date of Signature (mm/dd/yyyy)
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Part 11.
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.
[Number]
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)
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.
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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