| Part 7. Use of Assets to Supplement Income (Optional) (continued)
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9.
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Add together Item Numbers 6. - 8. and enter the number here.
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10.
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Add together Item Numbers 4., 5.b., and 9. enter the number here.
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| Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature
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| NOTE: Read the Penalties section of the Form I-864 Instructions before completing this part. |
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. |
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What is the Legal Effect of My Signing Form I-864?
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| 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.
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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 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?
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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. |
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What Does Signing Form I-864 Require Me To Do?
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| 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: |
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A.
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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
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B.
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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.
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What Other Consequences Are There?
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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.
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| 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.
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What If I Do Not Fulfill My Obligations?
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| 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.
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| Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and
Signature (continued) |
| 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. |
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When Will These Obligations End?
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| 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: |
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A.
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Becomes a U.S. citizen; |
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B.
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Has worked, or can receive credit for, 40 quarters of coverage under the Social Security Act;
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C.
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No longer has lawful permanent resident status and
has departed the United States;
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D.
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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 |
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E.
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Dies. |
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NOTE: Divorce does not terminate your obligations under Form I-864.
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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 Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
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Sponsor's Contact Information
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3.
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Sponsor's Daytime Telephone Number
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4.
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Sponsor's Mobile Telephone Number (if any)
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5.
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Sponsor's Email Address (if any)
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Sponsor's Declaration and Certification
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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 and all of my records that USCIS or DOS may need to
determine my eligibility for the benefit that 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. |
| 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. |
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A.
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I know the contents of this affidavit of support that I signed; |
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B.
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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 immigrants indicated in Part 3. to
become lawful permanent residents of the United
States; |
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C.
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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-864; |
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| Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature (continued)
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D.
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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;
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E.
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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-864; and
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F.
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I authorize the Social Security Administration to
release information about me in its records to
USCIS and DOS.
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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 affidavit.
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| Part 9. Interpreter's Contact Information, Certification, and Signature |
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Provide the following information about the interpreter.
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1.a.
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Interpreter's Family Name (Last Name)
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1.b.
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Interpreter's Given Name (First Name)
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2.
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Interpreter's Business or Organization Name (if any)
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Interpreter's Mailing Address
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Interpreter's Contact Information
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4.
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Interpreter's Daytime Telephone Number
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5.
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Interpreter's Mobile Telephone Number (if any)
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6.
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Interpreter's Email Address (if any)
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Interpreter's Certification
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7.a.
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Interpreter's Signature
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| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Affidavit, if Other Than the Sponsor
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| Provide the following information about the Preparer. |
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1.a.
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Preparer's Family Name (Last Name)
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1.b.
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Preparer's Given Name (First Name)
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2.
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Preparer's Business or Organization Name (if any)
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Preparer's Mailing Address
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Preparer's Contact Information
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4.
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Preparer's Daytime Telephone Number
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5.
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Preparer's Mobile Telephone Number (if any)
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6.
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Preparer's Email Address (if any)
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