Fillable Printable I 864W
Fillable Printable I 864W
I 864W
Form I-864W 07/02/15 NPage 1 of 5
Request for Exemption for
Intending Immigrant's Affidavit of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-864W
OMB No. 1615-0075
Expires 07/31/2017
START HERE - Type or print in black ink.►
Part 1. Information About You or Your Adopted
Child (Intending Immigrant)
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
This Form I-864W:
DOES NOT MEET
the requirements of
exemption
MEETS the
requirements
of exemption
For Government Use Only
Date (mm/dd/yyyy):
Reviewed By:
Location:
Name of Requestor
Mailing Address
If you answered "No" to Item Number 3., provide your
physical address.
3.Is your current mailing address the same as your physical
address?
YesNo
2.a. In Care Of Name
Street Number
and Name
2.b.
2.c.Ste.Flr.Apt.
2.d.City or Town
2.g.Province
2.i.Country
2.e.State2.f.ZIP Code
2.h.Postal Code
Other Information
Physical Address
4.g.Postal Code
4.h.Country
4.d.State4.e.ZIP Code
4.c.City or Town
Street Number
and Name
4.a.
4.bSte.Flr.Apt.
4.f.Province
Date of Birth (mm/dd/yyyy)
Alien Registration Number (A-Number) (if any)9.
►
A-
USCIS ELIS Account Number (if any)10.
►
5.
6.City or Town of Birth
7.State or Province of Birth (if applicable)
8.Country of Birth
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U.S. Social Security Number (if any)
11.
Form I-864W 07/02/15 NPage 2 of 5
Part 2. Reason for Exemption
I am EXEMPT from filing Form I-864, Affidavit of Support
Under Section 213A of the INA, because:
I have earned (or can be credited with) 40 quarters
(credits) of coverage under the Social Security Act
(SSA). (Attach SSA earnings statements. Do not
count any quarters during which you received a
means-tested public benefit.)
I am under 18 years of age, unmarried, immigrating
as the child of a U.S. citizen, and will automatically
become a U.S. citizen under the Child Citizenship
Act of 2000 upon my admission to the United States.
I am filing for an immigrant visa or adjustment of
status as a self-petitioning widow(er) using Form
I-360, Petition for Amerasian, Widow(er), or Special
Immigrant.
I am filing for an immigrant visa or adjustment of
status as a battered spouse or child using Form I-360.
1.a.
1.b.
1.c.
1.d.
2.
I have requested the services of and consented to
isis not an attorney or accredited
representative, preparing this request for me.
1.b.
The interpreter named in Part 4. has also read to me
every question and instruction on this request, as well
as my answer to every question, in
a language in which I am fluent. I understand every
question and instruction on this request as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
,
,
Part 3. Requestor's (Intending Immigrant's)
Statement, Contact Information, Certification,
and Signature
I can read and understand English, and have read and
understand every question and instruction on this
request, as well as my answer to every question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
who
NOTE: Read the information on penalties in the Penalties
section of the Form I-864W Instructions before completing this
part.
Requestor's Statement
Requestor's Mobile Telephone Number (if any)
Requestor's Daytime Telephone Number
Requestor's Contact Information
3.
4.
5.Requestor's Email Address (if any)
Requestor's Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS or the Department of State may require that I submit
original documents to USCIS or the Department of State at a
later date. Furthermore, I authorize the release of any
information from any and all of my records that USCIS or the
Department of State may need to determine my eligibility for
the immigration benefit that I seek.
I furthermore authorize release of information contained in this
request, in supporting documents, and in my USCIS or the
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws.
I certify, under penalty of perjury, that the information in my
request and any document submitted with my request were
provided by me and are complete, true, and correct.
Requestor's Signature
Date of Signature (mm/dd/yyyy)6.b.
Requestor's Signature (or U.S. citizen parent, if intending
immigrant is less than 14 years of age)
6.a.
NOTE TO ALL REQUESTORS: If you do not completely
fill out this request or fail to submit required documents listed
in the instructions, USCIS or the Department of State may deny
your request.
In addition, I authorize the Social Security Administration (SSA)
to release information about me in its records to the Department
of State and U.S. Citizenship and Immigration Services.
Form I-864W 07/02/15 NPage 3 of 5
3.h.
Interpreter's Mailing Address
3.c.City or Town
3.d.State3.e.ZIP Code
3.f.
3.g.
Province
Street Number
and Name
3.a.
Country
3.b.
Flr.Ste.Apt.
Postal Code
Interpreter's Contact Information
4.Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)5.
I have read to this requestor every question and instruction on
this request, as well as the answer to every question, in the
language provided in Part 3., Item Number 1.b.; and
Interpreter's Certification
I certify that:
which is the same language provided in Part 3., Item Number
1.b.;
I am fluent in English and
The requestor has informed me that he or she understands every
instruction and question on the request, as well as the answer to
every question, and the requestor verified the accuracy of every
answer.
,
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Request, If Other than the
Requestor
Provide the following information about the preparer.
Preparer's Mailing Address
3.c.City or Town
3.d.State3.e.ZIP Code
Street Number
and Name
3.a.
3.b.Flr.Ste.Apt.
3.h.
3.f.
Postal Code 3.g.
Country
Province
6.Preparer's Email Address (if any)
Preparer's Contact Information
4.Preparer's Daytime Telephone Number
5.Preparer's Fax Number
Interpreter's Signature
Date of Signature (mm/dd/yyyy)6.b.
Interpreter's Signature6.a.
Part 4. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Form I-864W 07/02/15 NPage 4 of 5
8.a. Preparer's Signature
8.b.Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this request on behalf of, at the request
of, and with the express consent of the requestor. I completed
this request based only on responses the requestor provided to
me. After completing the request, I reviewed it and all of the
requestor's responses with the requestor, who agreed with every
answer on the request. If the requestor supplied additional
information concerning a question on the request, I recorded it
on the request.
Preparer's Signature
I am not an attorney or accredited representative but
have prepared this request on behalf of the requestor
and with the requestor's consent.
I am an attorney or accredited representative and my
representation of the requestor in this case
7.a.
7.b.
Preparer's Statement
extends does not extend beyond the
preparation of this request.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this request, you must submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, with this
request.
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Request, If Other than the
Requestor (continued)
Form I-864W 07/02/15 NPage 5 of 5
3.d.
5.d.
Part 6. Additional Information
If you need extra space to provide any additional information
within this request, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this request or attach a separate sheet
of paper. Include your name and A-Number (if any) at the top
of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet.
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
2.A-Number (if any)
3.a.Page Number3.b.Part Number3.c.Item Number
5.a.Page Number5.b.Part Number5.c.Item Number
A-
4.d.
4.a.Page Number4.b.Part Number4.c.Item Number
6.d.
6.a.Page Number
6.b.Part Number6.c.Item Number
