I-864 Affidavit of Support Under Section 213A of the INA

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

For
USCIS
Use
Only

Affidavit of Support Submitter
Petitioner
1st Joint Sponsor
2nd Joint Sponsor
Substitute Sponsor
5% Owner

Section 213A Review
MEETS
requirements

USCIS
Form I-864
OMB No. 1615-0075
Expires 01/31/2026

Number of Support Affidavits in File

DOES NOT MEET
requirements

1

2

Remarks
Reviewed By:
Office:
Date (mm/dd/yyyy):

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

To be completed by an
Attorney or Accredited
Representative (if any).

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. Basis For Filing Affidavit of Support

I, am the sponsor submitting this affidavit of support because (Select only one box).
1.a.

I am the petitioner. I filed or am filing for the immigration of my relative.

1.b.

I filed an alien worker petition on behalf of the intending immigrant,who is related to me as my

1.c.

I have an ownership interest of at least 5 percent in

which filed an alien worker petition on behalf of the intending immigrant, who is related to me as my

1.d.

I am the only joint sponsor.

1.e.

I am the

1.f.

The original petitioner is deceased. I am the substitute sponsor. I am
the intending immigrant's

first

second of two joint sponsors.

NOTE: If you are filing this form as a sponsor, you must include proof of your U.S. citizenship, U.S. national status, or lawful
permanent resident status.

Part 2. Information About You (Sponsor)
1.

Sponsor's Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

Form I-864 Edition 01/23/24

Given Name (First Name)

Middle Name (if applicable)

Page 1 of 12

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

Sponsor's Current Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

ZIP Code

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Postal Code

Country

Is your current mailing address the same as your physical address?

Yes

No

Yes

No

If you answered "No" to Item Number 3., provide your physical address in Item Number 4.
4.

Sponsor's Physical Address (if different from the address above)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Other Information
5.

Country of Domicile

8.

U.S. Social Security Number (Required)
►

9.

Immigration Status

6.

Date of Birth (mm/dd/yyyy)

7.

Country of Birth

I am a U.S. citizen.

I am a U.S. national.

I am a lawful permanent resident.
10

Sponsor's A-Number (if any)
► A-

11.

USCIS Online Account Number (if any)
►

Military Service (To be completed by petitioner sponsors only.)
12.

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

Form I-864 Edition 01/23/24

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Part 3. Information About the Principal Immigrant
1.

Principal Immigrant's Full Legal Name (Do not provide a nickname)
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name (if applicable)

Sponsor's Current Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

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City or Town

Province

State

Postal Code

ZIP Code

Country

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.

►

Daytime Telephone Number

Part 4. Information About the Immigrants You Are Sponsoring
1.

I am sponsoring the principal immigrant named in Part 3.
Yes

No (Applicable only if you are sponsoring family members in Part 4. as the second joint sponsor or if you are
sponsoring family members who are immigrating more than six months after the principal immigrant)

2.

I am sponsoring the following family members immigrating at the same time or within six months of the principal
immigrant named in Part 3. (Do not include any relative listed on a separate visa petition.)

3.

I am sponsoring the following family members who are immigrating more than six months after the principal immigrant.

4.

Family Member 1
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Relationship to Principal Immigrant

Date of Birth (mm/dd/yyyy) Alien Registration Number (A-Number, if any)
►

USCIS Online Account Number (if any)
►

Form I-864 Edition 01/23/24

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Part 4. Information About the Immigrants You Are Sponsoring (continued)
5.

Family Member 2
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Relationship to Principal Immigrant

Date of Birth (mm/dd/yyyy) Alien Registration Number (A-Number, if any)
►

USCIS Online Account Number (if any)
►
6.

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Family Member 3

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Relationship to Principal Immigrant

Date of Birth (mm/dd/yyyy) Alien Registration Number (A-Number, if any)
►

USCIS Online Account Number (if any)
►
7.

Family Member 4

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Relationship to Principal Immigrant

Date of Birth (mm/dd/yyyy) Alien Registration Number (A-Number, if any)
►

USCIS Online Account Number (if any)
►

If you need additional space, use the space provided in Part 11. Additional Information.

Form I-864 Edition 01/23/24

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For
USCIS
Use
Only

Part 5. Sponsor's Household Size
NOTE: Do not count any member of your household more than once.
Persons you are sponsoring in this affidavit:
1.

Enter the total number of immigrants you are sponsoring on this affidavit which includes the principal immigrant
listed in Part 3., any immigrants listed in Part 4., Item Numbers 4. - 7. and, any additional sponsored immigrants
you listed in Part 11. Additional Information. Do not count the principal immigrant if you are only sponsoring
family members entering more than six months after the principal immigrant.

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Persons NOT sponsored in this affidavit:
2.

Yourself.

3.

If you are currently married, enter "1" for your spouse.

4.

If you have dependent children, enter the number here.

5.

If you have any other dependents, enter the number here.

6.

If you have sponsored any other persons on Form I-864 or Form I-864EZ who are now lawful permanent residents
and you are still obligated to support, enter the number here.

7.

If you have siblings, parents, or adult children with the same principal residence who are combining their income
with yours by submitting Form I-864A, enter the number here.

8.

Add together Part 5., Item Numbers 1. - 7. and enter the number here.

Household Size:

Part 6. Sponsor's Employment and Income
I am currently:
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.

Form I-864 Edition 01/23/24

Page 5 of 12

For
USCIS
Use
Only

Part 6. Sponsor's Employment and Income (continued)
8.

Person 1
Name

Relationship

Current Income
9.

Person 2
Name

10.

Name

11.

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Current Income
Person 3

Current Income
Person 4
Name

Current Income

Remarks
12.

$

Relationship

$

Relationship

$

Relationship

$

My Current Annual Household Income (Total all lines from Part 6. Item Numbers 7. - 11.;
the total will be compared to Federal Poverty Guidelines on Form I-864P.)

$

13.

The people listed in Item Numbers 8. - 11. have completed Form I-864A. I am filing along with this affidavit all necessary
Form I-864As completed by these people.

14.

One or more of the people listed in Item Numbers 8. - 11. do not need to complete Form I-864A because he or she is the
intending immigrant and has no accompanying dependents.

Federal Tax Return Information
15.

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
16.

17.

Total Income

Most Recent

$

2nd Most Recent

$

3rd Most Recent

$

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.

Form I-864 Edition 01/23/24

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For
USCIS
Use
Only

Household Size
2
1
3
4
5
6
7
8
9
Other

Poverty Guideline

Sponsor's Household Income

Remarks

(Page 5, Line 10)

Year: 2 0
Poverty Line:
$

$
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.

Part 7. Use of Assets to Supplement Income (if Applicable)
If your income, or the total income for you and your household, from Part 6., Item Numbers 12. or 16. exceeds the Federal Poverty
Guidelines for your household size, YOU ARE NOT REQUIRED to complete this Part 7. Skip to Part 8.
Your Assets (if applicable)

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1.

Enter the balance of all cash, savings, and checking accounts.

$

2.

Enter the net cash value of real-estate holdings. (Net value means 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.

$

Assets of your household members (if applicable)

Your household members who are combining their income with yours, report their assets on Form I-864A Part 4., in Item Number 6.
5.

Add together the household members' assets reported on all the Form I-864A
Part 4., Item Number 6. and enter the number here.

TOTAL: $

Assets of the principal sponsored immigrant (if applicable).

The principal sponsored immigrant is the person listed in Part 3., Item Number 1. Only include the assets if the principal immigrant
is being sponsored by this affidavit of support.
6.

Enter the balance of the principal 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.

$

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. Sponsor's Contract, 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.

Form I-864 Edition 01/23/24

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Part 8. Sponsor's Contract, Contact Information, Certification, and Signature (continued)
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.

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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.
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.

Form I-864 Edition 01/23/24

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Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature
(continued)
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.

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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.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

Sponsor's Statement
1.

Sponsor's Statement Regarding the Interpreter
A.
B.

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.
The interpreter named in Part 9. read to me every question and instruction on this affidavit and my answer to every
question in
everything.

2.

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

At my request, the preparer named in Part 10.,

, 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-864 Edition 01/23/24

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Part 8. 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 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 immigrant
indicated in Part 3. 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 9. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization 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 and Signature
I certify, under penalty of perjury, that: that I am fluent in English and

, and I have interpreted every

question on the affidavit and Instructions and interpreted the sponsor's answers to the questions in that language, and the sponsor
informed me that they understood every instruction, question, and answer on the affidavit.
6.

Interpreter's Signature

Form I-864 Edition 01/23/24

Date of Signature (mm/dd/yyyy)

Page 10 of 12

Part 10. 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

Preparer's Given Name (First Name)

Preparer's Contact Information

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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 affidavit for the sponsor at their request and with express consent and that all of
the responses and information contained in and submitted with the affidavit are complete, true, and correct and reflects only
information provided by the sponsor. The sponsor reviewed the responses and information and informed me that they understand the
responses and information in or submitted with the affidavit.
6.

Preparer's Signature

Form I-864 Edition 01/23/24

Date of Signature (mm/dd/yyyy)

Page 11 of 12

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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Form I-864 Edition 01/23/24

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