I-864EZ Affidavit of Support of Support Under Section 213A of th

USCIS
Form I-864EZ

Affidavit of Support Under Section 213A of the INA
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0075
Expires 01/31/2026

For Government Use Only
This Form I-864EZ:
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):

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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
1.

I am the petitioner of the family member sponsored on this affidavit.

Yes

No (Use Form I-864)

2.

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)

3.

The sponsored immigrant is the only person immigrating based on
the underlying visa petition.

Yes

No (Use Form I-864)

Part 2. Information About You (Sponsor)
1.

Family Name (Last Name)

2.

Current Mailing Address

Given Name (First Name)

Middle Name (if applicable)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Postal Code

ZIP Code

Country

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.

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Part 2. Information About You (Sponsor) (continued)
4.

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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Other Information
5.

Country of Domicile

6.

Date of Birth (mm/dd/yyyy)

7.

Country of Birth

8.

U.S. Social Security Number (if any)

►

9.

Immigration Status

I am a U.S. citizen.

I am a lawful permanent resident.
I am a U.S. national.
10.

Sponsor's A-Number (if any)
► A-

11. USCIS Online Account Number (if any)
►

Military Service
12.

I am currently on active duty in the United States Armed Forces or U.S. Coast Guard.

Yes

No

Part 3. Information About the Immigrant You Are Sponsoring (Intending Immigrant)
1.

Name of Immigrant

Family Name (Last Name)

2.

Given Name (First Name)

Middle Name (if applicable)

Current Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr.

City or Town

State

Province

Form I-864EZ 01/23/24

Postal Code

Number

ZIP Code

Country

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Part 3. Information About the Immigrant You Are Sponsoring (Intending Immigrant) (continued)
Other Information
3.

Country of Citizenship or Nationality

4.

Date of Birth (mm/dd/yyyy)

5.

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

6.

USCIS Online Account Number (if any)

► A7.

►

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Daytime Telephone Number

Part 4. Information About Your Household Size
NOTE: Do not count any household member more than once.
1.

Yourself and the person you are sponsoring on this Form I-864EZ.

2.

Your spouse. (NOTE: Enter "0" if you already counted your spouse in Item Number 1.)

3.

Your dependent children under 21 years of age. (NOTE: Enter "0" if you already counted your dependent children in
Item Number 1.)

4.

If you have sponsored any other persons on a Form I-864 who are now lawful permanent residents in the
United States and you are still obligated to support enter the number here. (NOTE: Enter "0" if you already
counted these persons in Item Number 1.)

5.

If you have any other dependents listed on your most recent Federal income tax return, enter the number here.
(NOTE: Enter "0" if you already counted your other dependents in Item Number 1.)

6.

Add together Item Numbers 1. - 5. and enter the number here. This is your HOUSEHOLD SIZE for the
purpose of this Form I-864EZ.

Part 5. Information About Your Employment and Income
1.

I am currently:

Employed (Complete Item Number 2.)
Retired (Complete Item Number 3.)
2.

Current Occupation
Name of Employer 1

3.

Name of Employer 2 (if applicable)

Date of Retirement (mm/dd/yyyy)

4.

My current individual annual income

$

Federal Income Tax Informtion
5.

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.
My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal income tax returns for the most recent three years was:
Tax Year
6.

Total Income

Most Recent

$

2nd Most Recent

$

3rd Most Recent

$

Form I-864EZ 01/23/24

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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.

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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.

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.

Form I-864EZ 01/23/24

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Part 6. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature
(continued)
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:

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

2.

At my request, the preparer named in Part 8.,

, prepared this affidavit

for me based only upon information I provided or authorized.

Sponsor's Contact Information
3.

Sponsor's Daytime Telephone Number

5.

Sponsor's Email Address (if any)

4.

Sponsor's Mobile Telephone Number (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.
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.

Form I-864EZ 01/23/24

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Part 6. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature
(continued)
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 the USCIS and DOS.

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Sponsor's Signature
6.

Sponsor's Signature

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 request.

Part 7. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that: that I am fluent in English and

, and I have interpreted every

question on the contract and instructions and interpreted the sponsor's or household member's answers to the questions in that
language and the sponsor or household member informed me that he or she understood every instruction, question, and answer on the
contract.

Interpreter's Signature
6.

Interpreter's Signature

Form I-864EZ 01/23/24

Date of Signature (mm/dd/yyyy)

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Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Affidavit, if Other
Than the Sponsor
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

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Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this contract for the sponsor and household member at their request and with express
consent and that all of the responses and information contained in and submitted with the contract are complete, true, and correct and
reflects only information provided by the sponsor and household member. The sponsor and household member reviewed the
responses and information and informed me that they understand the responses and information in or submitted with the contract.
6.

Preparer's Signature

Form I-864EZ 01/23/24

Date of Signature (mm/dd/yyyy)

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Part 9. Additional Information
If you need extra space to provide any additional information within this contract, 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 contract 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.
1.

Family Name (Last Name)

Given Name (First Name)

2.

A-Number (if any) ► A-

3.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

Middle Name (if applicable)

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