Affidavit of Support section 213A Number of Support

Submitter Cl MEETS CJ DOES NOT MEET Affidavits in File

C] Petitioner requirements requirements
Remarks
For 1st Joint Sponsor
2nd Joint Sponsor
Use
Substitute Sponsor
Only
Owner
Rcviewed By
Office:
Date

To be completed C] Select this Attorney State Bar Attorney or Accredited

by an attorney box if Form Number Representative
or accredited G-28 or USC'S Online Account Number
representative G-281 is (if any)
(if any). attached.
START IIERE - Type or print in black ink.

Part 1. Basis For Filing Affidavit of Support MailingAddress

IOMARÄ ENCARNACION In Care Of Name
ULCE M VALDEZ YNOA
am the sponsor submittingthis affidavit of Support because
(Select only one box): Street Number
DUARTE SANTO CERRO
I am the petitioner. I filed or am filing for the and Name
immigration ofmy relative
I filed an alien worker petition on behalf of the intending
immigrant, who is related to me us my 2.d. City or Town LA VEGA

2.f. ZIP code

I have an interest Of at least 5
owners ercent in
LA VEGA
Postal
which Code
filed an
alien wnrker petition on behalf Of the 2.11. Country
Incendin immi rant, Who is related to me m NICAN REPUBLIC

I am thc only joint Sponsor,

I am the first second joint sponsors
Other
C] The original petitioner is deceased. am
the 3
.

Edition
NOTE: If you are filing this form as a sponsor, you must 4.
bateof Birth10/11/1950
include proof oryour U.S. citizenship,
Alien Registration Number
L'S. national status, ur lawful 5. ( ifanv
permanent resident status.
Part 2. Information About the Principal6. USCIS Online
Account Number Immigrant
La. Family Namc7. Daytime Telephone Number
VALDEZ YNOA
(Lust
Name) Lb.
Given Namc DULCE
(First Name)

Edition
 (Last Name)
I sponsoring the principal immigrant 'Yamcd in part 2. Given Name

Edition
 Yes No (Applicable only if you aresponsoring (First Name) familv
members in Part 3. as the second joint sponsor or if you are sponsoring
family members Who are immigrating more than six months after the
principal immigrant)
lam sponsoring the fOllowing family members
immigrating al the same Lime Or Within six months of
the principal immigrant named in Part 2. (Do not
include any rialive listed On a separate visapetition.)
am sponsoring the 10110Wing family members who ate

Part 3. Information About the Immigrants You

Are Sponsoring (continued)
immigrating more than six months after the principal
PhysicalAddi•éss
Street Number
29. Enter the total number of immigrants you are sponsoring on this
affidavit which includes the principal immigrant listed in part
any immigrants listed in Part 3.. Item Numbers l. - 28. and (if
applicable). any immigrants listed for these questions in part
Additional Information. DO not count the principal immigrant if
you are only sponsoring family members entering more than 6
months afterthc principal immigrant.

Pai•t4. MOrmatiouAbout
If you answered "No" to Item Number provide your
Name physical address in Item Numbers - 4.h.
Family Name and Name
(Last Name)
4.b. Apt,
Lb. Given Name
(Firs! Name) City or Town State code
I.e. Middle Name
province

Mailing Postal Code

tn Care OfName
SOUTH TERRACE AVENUE 4.h. Country

Street Number and Name Apt.

MOUNT VERNON
2.d. city or NY
2.r. ZIP Code 10550 Coun of Domicile
Town

2.e. State
6. Date of Birth (mm/dd.\yyyy) 08/01/1972
7. Ci or Town of Birth

VEGA
8.
State or province Of Birth

Count of Birth
Edition DCMINICAN REPUBLIC
9.

U.S. Social Security Number (R uiredj

yos7023
Citizenship or Residency

Military
14.

Edition
6, W you have sponsored any Other persons on
Form 1-864 or Form 1-8641M Who are now
lawful permanent residents, enter the
number here.

7. OPTIONAL; If you have siblings. parents,

or adult children with the same principal
rcsidcncc whcyare combining their income
with yours by submitti Form enter the
number here.

Add together part Item Numbers l. - 7.•and

enter the number here.
Household Size:
Person
Nam
part
e

14.

Edition
lam currently;
15.

16.
2.Name Of Etn 10 er I
NEW VISION HOME CARE Person 4
3 lica
. ble

Edition
 24.e. 3rd Most Recent
part 6. Sponsor's Employment and Income.
(continued)
20. Household Sile Poverty Guideline Remarks

Poverty I-inc:

other
0102
My Current Annual Ilousehold Income (Total all lines from Part 6.
Item Numbers 7 the total will bc
compared to Federal poverty Guidelines on 25. was not required to file a Federal income tax return JS
my income was below the IRS required lcwel and I
Form,
$
43,366.00 have attached evidence Xo support this.
art UseofAssets to Supplement income
21. The people
completed Form I am filing along with this
nal)
Ifyour income, or the total income thr you and your household.
aflidavit all necessary Form 1-864As completed from Part 6.. Item Numbers 20. or 24.a. - 24.c„ exceeds Federal
by these people. Poverty Guidelines for your household sim_ VOU ARE NOT
22. One or more of the people listed in Item Numbers REQUIRED to Part 7. Skip to Part 8.
ll., 14., and 17. do not nccd to complete Form 1-86AA Your Assets (Optional)
because he or she is the intending immigrant and has
Enter the balance Ofall Savings and checkin ' accounts,

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

no accompanyingdependents.
value meanseurrent assessed value minus mortgage debt. )

Enter the net cash valueofall stocks, bonds. certificates of deposit.

Federal Income Tax Return Information and any other assets not already included in Item Number l. or
Item Number 2.
23.a. Have you filed a Federal income tax return for each ofthc
three most recent tax years?
NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most
recent lax year.

23.b, (Optional) I have attached photocopies or

transcripts Of my Federal income tax returns for
my second and third most revcnt yeam.

My total income (adiusled gross income on Internal Revcnuc Add together Item Numbers I. 3. and enter here.
Service (IRS) Fonn 10401M) as reported On my Federal income TOTAL: S
returns for the most recent three years was;
Assets from Form 1-864A, Part 4.. Item Number 3.d.. for:
ear Total Income
24.a. Most Recent 2021 $ 43,366.00 Assets of the principal sponsored immigrant ( optional j.
24,b. 2nd Most Recent

-864
The principal sponsored immigrant is the person listed in part 2..
Item Numbers I-a. - Only include the assets if the principal
immigrant is being sponsored by this allidavil of Support.
6. Enter the balance of the principal immigrant's savings
and checking accounts.
7. Enlerlhe net cash value of all the principal immigrant's real
estate holdings. (Net valuc means investment value minus
mortgage debt.)
8. Enter the current Cagh 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
t O. Add logether Item Numbers
number here.
'IOTAL: S
Part S. Sp Con Statement, C
Information, Declarations Certification/and
Si ature
NOTE: Read thc Penalties section of the Form 1-864 Instructions
before completing this part.
Spo
Please note that, by signing this Form 1-864. you agree to assume
certain spccific obligations under Ihehnrnigration and Nationality
Act (INA) and other Federal laws. The following paragraphs
describe those obligations. Please read the following information
carefully bctOre you sign Form 1-864. If you do not understand
the obligations, you may Wish to consult an attorney or accredited
representative.
-864
What is the Legal Effect of My Signing Form 1-864?
If you sign Form 1-864 on behalf of any person (called the
intending immigrant) who is applying for an immigrant visa or
a
Choose Not to Sign Form djustment Of
status to a lawful permanent and that intending immigrant submits
Form 1-864 to the l',S, Government With his Or her application tar
an ilnmigrant 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. yowagTce that, in deciding whether the
intending immigrant Can establish that he or she is inadmissible
to the Uniled Slates as a person likely to become a public charge,
the ILS. Government can consider your income and assets as
available for the support Of the intending unm;grant.
do not want to do so. But if you do not sign Form 1-864.
intending immigrant may not become a permanent
resident in the United Stales.
What Does Signing Form 1-864 Require Me TO Do
(fan intending immigrant becomens lawful permanent resident
in the United States based on a Form 1-864 that you ltdve signed.
then, until your obligations under Form 1-864 (erminate, you
must:
A. Provide the intending immigrant any 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 peæcnt if' you are the petitioning
sponsor and are on active duty ill the U.S. Armed
Forces or U.S. Guard. arid the person is your
husband. wife. or unmarried child under 21 years Of
age): and
Notify U.S. Citizenship and Immigralion Services
(USC[S) of any change in your address, within 30
days ofthe change, by filing Form 1-865.
What Other Consequences Are Tlaere?
Il
l
If an intending immigrant becomes a law(ul permanent residenl
in the United Slates based on a Form 1-864 that you have signed,
then. until your obligations under Form 1-864 terminate.
the US. Government may consider (deem) your income and
assetsaS available to that person. in determining whether he or she
is eligible fur certain Federal means-tested public benefits and also
for Stale 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 tu the person.
This provision does not apply 10 public benefits specified in
section 403(c) of the Welfare Reform Aet such as emergency
Medicaid. short-term, non-cash emergency relief: services
provided under the National School t_unch and Child Nutrition
Acts; immunizations and testing and Irealrnent for
communicable diseases; and means-tested programs u lider the
Elementary and Secondary Education Act.
What If I Do Not Fulfill My Obligations?
If you do not provide sulTlcicntsupporI 10 [he person who
becomes a lawful permanent resident based On a Form 1-864
that you signed, person may suc you for this support.
Parts. Sponsor'S Contract. Statements Contact
Information, Declarati0'G Certification, and
ature (continu
Ifa Federal. state, local, or private agency provided any covered
means-tested puhiic benefit to the person who becomes a lawful
permanent rcsidcnt hased on a Form 1-864 that you signed, the
agency may you to them the amount of the benefits they provided.
If you do nol make the reimbursement, the agency may sue you for
the amount that the agency believes you:owe.
you are sued, and the court enters a judgment against you. the
person or agency [bal sued you may use any legally permitted
procedures for or collecting thejudgment. You may also bc
required to pay the costs of collection, including attorney
fCcs_
[f you do not filc a properly completed Form within 30 daysof
any change of address, may imposc a civil fine tar your failing to
do so.
B. Has worked. or can receive credit for. 40 quatters of
coverage undcr thc Social Security Act:
C. NO longer has permanent resident status and has
departed the United States;
Is subject to removal, butapplies for and obtains, in
removal proceedings. a grant Of adjustment
status, based On a newaffidavit of support. if one is
required; or
E. Dies.
NOTE: Divorce does not terminate your obligations under Form
1-864.
Your obligations under a Form 1-864 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 estatc may owe any support that yow ;iceumulated betarc you
died.
Sponsor
Statement thebox forcitherItemNumber Or
The interpreter named in part 9. read to me every
question and instruction on this and my answer to
every question in
NOTE: Select
If applicable. select the box for Item Number 2.
I.a. [can read and understand F.nglish, and I have read and
understand every question and instruction On this
affidavit and myanSWer to every question.
a language in which fluent. and I understood
everything.
At my request. the preparer named in part 10..
prepared this affidavit for me based only upon
information I prvvided or authorized.

When Will These Obligations End?

Your obligations undera Form 1-864 that you signed will end if
the person Who becomes a lawful permanem resident based on
that atfldavit:

A. Beepmcs a U.S. citizen;

-864

4.
Copies Of any dcxuments I have are exact photocopies of
unaltered. Original documents. and I understand that USC[S or the
U.S. Department of State (DOS) may require that I submit
Original documents to USCIS or DOS at later date. Furthermore,
[authorize release of any inroonation from any and all ormy
records that [JSCIS or DOS may need to determine my ehgibility
for the benefit that I seek
Federal or state court that has sul!iect matter jurisdiction of a
-864
[ tüffhcrmore authorize relcaseofinlOr1natiOn contained in this
allidavit, in supporting documents, and in my USC(IS or DOS
records, to other entities and persons where necessary for the
administration and enforcement immigration law.
I certify, under pcna]ty of perjury, that all of the information in my
affidavit and any document submitted with i' provided or
authorized by me, that I reviewed and understand all Of
information contained in, and submitted with, my and that
all of this inlörmution is complete. true, andeorrecl.
I know the contents Of this affidavit ofSupport that I
signed;
B. have read and I understand each ofthe obligations
described in Part 8., and agree. freely and without any
mental reservation or purpose Of evasion. 10 accept
cach of those Obligations in order make it possible for
the immigrants indicated in Part 3. to become lawt;al
permanent residcnts Clnited States;
C. I agree to submit to the personal jurisdiction ot•any
against me to my Obligations under this Form
NOTE TO ALL SPONSORS: If you do not completely fill out
this affidavit or fail to submit required documents listcd in Int reter's Business or izaLion Name (if an )
the]nstructions, USCIS or DOS may deny your dlTldavit.

Part". Interpreter'S COntaCfInformatiOn, Certifi

Certification, aud Signature cation
Provide Ithe IOlowing inturmation about the interpreter.
I certify, under penalty of perjury, that:
arn fluent in English and which is the Same language Specified
Interpreter'SFull in Part 8.. Item Number I .b., and I have read 10 this sponsor in
r the identified language every question and instruction on this
e ailidavit and his her answer to every question. The sponsor
t inlQUi11ed me that she understands every instruction. quesrion.
e and answer Oil the atf:davit, including the Sponsor's Declaration
Int retc•es Given Name, First Name r and
' Certification, and has verified (he accuracy of answer.
s
Signgi
Famil Name (Last Name)
ure

Inte Si ture

Lb.
Date ofSignature
 Part 10. Contact Information, Declaration;and
Signature of the Person Preparing this Affidavit/
ifOther Than the S nsor

Preparer'S
C] lam not an attorney or accredited represenlativc bill have prepared this affidavit on behalf oi the sponsor Provide the
following information about the preparer. and With the sponsor's consent.
I am an attorney Or accredited representative
my

docs not estend beyond (he

6. arer's Email Address (if an )
spacethanWhat is provided.youmaymakecopies Of this page
tocompleteandtileWith this alfidavilor attacha separatesheet
need extra Space to provide any additional information within
[his alfldavit. use the space below. If you need more

of paper. Type or print your name and A-Nurnber any) at the top of
cach sheet: indicate the Page Number, Part Number, and Item
Number to Which your answer refers: and sign and date each sheet.

Famil ENCARNACION
Name)
y
Lb. Given Name XIOMARA
(First Name)

e Number 6.1).

Part Number