Form I-864 07/02/15 N
Page 8 of 12
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.
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 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.
What If I Do Not Fulfill My Obligations?
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
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
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.
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.
No longer has lawful permanent resident status and has
departed the United States;
Becomes a U.S. citizen;
When Will These Obligations End?
Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;
Your obligations under a Form I-864 that you signed will end if
the person who becomes a lawful permanent resident based on
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
NOTE: Divorce does not terminate your obligations under
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.
1.b. The interpreter named in Part 9. has also read to me
every question and instruction on this affidavit, as
well as my answer to every question, in
a language in which I am fluent. I understand every
question and instruction on this affidavit as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
I can read and understand English, and have read and
understand every question and instruction on this
affidavit, as well as my answer to every question.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
Part 8. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature