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Sample Form I-864, Affidavit of Support

Sample Form I-864, Affidavit of Support

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Published by: crossbordermarriage on Jan 11, 2012
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04/14/2014

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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
LocationDate
(mm/dd/yyyy)
1. I,
Part 2. Information on the principal immigrant.
3.
Mailing Address Street Number and Name
(Include Apartment Number)
This I-864 is from:
Reviewer 
 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.
This I-864:
the Petitioner a Joint Sponsor # ______________ the SubstituteSponsor 
Department of Homeland Security
U.S. Citizenship and Immigration Services
5% Owner 
First Name
OMB No. 1615-0075; Expires 10/31/2011
Part 1. Basis for filing Affidavit of Support.
Middle Name
2.
Last NameCityState/ProvinceZip/Postal CodeCountry
4.
Country of Citizenship
5.
Date of Birth
(mm/dd/yyyy)
6.
Alien Registration Number 
(if any)
A-7.
U.S.
 
Social Security Number 
(if any)
Part 3. Information on the immigrant(s) you are sponsoring.
8.
b.c.d.a.
U.S.Social Security Number 
(if any)
Date of Birth
(mm/dd/yyyy)
 
A-Number 
(if any)
 NameRelationship toSponsored Immigrant
e.
10.
Enter the total number of immigrants you are sponsoring on this form from
Part 3
, Items
8
and
9
.I am sponsoring the principal immigrant named in Part 2 above.
9.
I am sponsoring the following family members immigrating at the same time or within six months of the principalimmigrant named in
Part 2
above. Do not include any relative listed on a separate visa petition.YesNo (Applicable only in cases with two joint sponsors)
12
I am the only joint sponsor.
a
.
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
b
.
I have an ownership interest of at least 5 percent in
c
.
d
.
I am the
e.
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
 
I am a lawful permanent resident. My alien registration number is A-
Part 4. Information on the Sponsor.
Middle Name
Form I-864 (Rev. 10/08/10)Y Page 2
Last NameFirst Name
11.
 Name
16.
Date of Birth
(mm/dd/yyyy)
CityStreet Number and Name
(Include Apartment Number)
Country
13.
Place of Residence
(if different frommailing address)
14.
Telephone Number 
(Include Area Code or Country and City Codes)
15.
Country of Domicile
19.
Citizenship/ResidencyIf you checked box (b), (c), (d), (e) or (f) in line 1 on Page 1, you must include proof of your citizen, national, or permanent resident status.
Zip/Postal CodeState or Province
20.
Military Service (To be completed by petitioner sponsors only.)
12.
Mailing Address
Street Number and Name
(Include Apartment Number)
CityState or ProvinceZip/Postal CodeCountry
17.
Place of Birth
(City)
CountryState or ProvinceI am currently on active duty in the U.S. armed services.
For GovernmentUse Only
18.
U.S. Social Security Number 
(Required)
I am a U.S. citizen.I am a U.S. national (for joint sponsors only). NoYes
2222 MINNESOTA AVENUEMINNEAPOLIS MNUSA 5555511111 PENANG STREETGEORGE TOWN PENANGMALAYSIA 11111454-545-4554USAMINNEAPOLIS MN USAWASHINGTONMARK GEORGE111-11-111106/03/1978
 
(Date)
21.
Your Household Size -
DO NOT COUNT ANYONE TWICE
Part 5. Sponsor's household size.
 Persons you are sponsoring in this affidavit:
a.
Enter the number you entered on line 10.
 Persons NOT sponsored in this affidavit:
b
. Yourself.
Part 6. Sponsor's income and employment.
22.
 
I am currently:
e.
If you have any other dependents, enter the number here.
c.
If you are currently married, enter "1" for your spouse.
d
. If you have dependent children, enter the number here.
Form I-864 (Rev. 10/08/10)Y Page 3
1
For GovernmentUse Only
23. My current individual annual income is:
$
(Company Name)(Date)
OPTIONAL
:
If you have siblings, parents, or adult children withthe same principal residence who are combining their incomewith yours by submitting Form I-864A, enter the number here.If you have sponsored any other persons on an I-864 or I-864 EZwho are now lawful permanent residents, enter the number here.
f.g.
Add together lines and enter the number here.
Household Size:h
.
(See Step-by-Step Instructions)
Employed as a/an
a.
 Name of Employer #1
(if applicable)
  Name of Employer #2
(if applicable)
Self-employed as a/an
b
.Retired from
c.
Unemployed since
d.
since......
0 10 20.0001/01/2011

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