For GovernmentUse Only
which filed an alien worker petition on behalf of the intending immigrant, who is related tome as my
I-864, Affidavit of SupportUnder Section 213A of the Act
Part 2. Information on the principal immigrant.
Mailing Address Street Number and Name
(Include Apartment Number)
This I-864 is from:
Number of Affidavits of Support in file:
Form I-864 (Rev. 10/08/10)Y
does not meet therequirements of section 213A.meets therequirements of section 213A.
the Petitioner a Joint Sponsor # ______________ the SubstituteSponsor
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0075; Expires 10/31/2011
Part 1. Basis for filing Affidavit of Support.
Last NameCityState/ProvinceZip/Postal CodeCountry
Country of Citizenship
Date of Birth
Alien Registration Number
Social Security Number
Part 3. Information on the immigrant(s) you are sponsoring.
U.S.Social Security Number
Date of Birth
NameRelationship toSponsored Immigrant
Enter the total number of immigrants you are sponsoring on this form from
.I am sponsoring the principal immigrant named in Part 2 above.
I am sponsoring the following family members immigrating at the same time or within six months of the principalimmigrant named in
above. Do not include any relative listed on a separate visa petition.YesNo (Applicable only in cases with two joint sponsors)
I am the only joint sponsor.
I am the petitioner. I filed or am filing for the immigration of my relative.I filed an alien worker petition on behalf of the intending immigrant, who is related to me asmy
I have an ownership interest of at least 5 percent in
I am the
The original petitioner is deceased. I am the substitute sponsor. I am the intendingimmigrant's
f.am the sponsor submitting this affidavit of support because (Check only one box):,,.
firstsecond of two joint sponsors.
(Check appropriate box.)
N/AMARK GEORGE WASHINGTONDOEJANE MARY111 PENANG STREETGEORGE TOWN PENANG 11111 MALAYSIAMALAYSIAN/A N/A0 110/15/1979