Sponsor's Notice of Change of Address Form

Fillable Printable Sponsor's Notice of Change of Address Form

Sponsor's Notice of Change of Address Form

Page 1 of 5Form I-865 07/17/15 N

For

USCIS

Use

Only

Sponsor's Notice of Change of Address

Department of Homeland Security

U.S. Citizenship and Immigration Services

START HERE - Type or print in black ink.►

USCIS

Form I-865

Action Block

Resubmitted

Remarks

Part 1.

Information About You (Sponsor)

CSID Number:

Date

Returned

Date

Your New Physical Address

1.b.

1.c.

1.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

Your Full Name

City or Town3.c.

Street Number

and Name

3.a.

3.b. Apt.

Flr.

Ste.

3.f.

3.h.

Province

Country

3.g.

Postal Code

ZIP Code

3.e.

State

3.d.

Other Information

2. Date of Birth (mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy) (mm/dd/yyyy)

(mm/dd/yyyy)

Effective Date of Change of Address (mm/dd/yyyy)4.

City or Town6.d.

Street Number

and Name

6.b.

6.c. Apt.

Flr.Ste.

6.g.

6.i.

Province

Country

6.h.

Postal Code

ZIP Code

6.f.

State

6.e.

Effective Date of Change of Address (mm/dd/yyyy)7.

1.b.

1.c.

1.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

Part 2. Information About the Sponsored

Immigrants

Provide the requested information on the persons you are

sponsoring.

In Care Of Name (if any)6.a.

Your New Mailing Address

Is your new physical address the same as your new

mailing address?

NoYes

If you answered "No" to Item Number 5., provide your

new mailing address in Item Numbers 6.a. - 7.

Sponsored Immigrant 4

7.b.

7.c.

7.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

A-Number (if any)8.

A-

►

1.b.

The interpreter named in Part 4. has also read to me

every question and instruction on this notice, as well

as my answer to every question, in

a language in which I am fluent. I understand every

question and instruction on this notice as translated to

me by my interpreter, and have provided complete,

true, and correct responses in the language indicated

above.

I have requested the services of and consented to

is is not an attorney or a accredited

representative, preparing this notice for me.

who

Sponsor's Contact Information

Sponsor's Daytime Telephone Number

Sponsor's Mobile Telephone Number (if any)

Sponsor's Email Address (if any)

Copies of any documents I have submitted are exact

photocopies of unaltered, original documents, and I understand

that USCIS may require that I submit original documents to

USCIS at a later date. Furthermore, I authorize the release of

any information from any and all of my records that USCIS

may need to determine my eligibility for the immigration

benefit that I seek.

Sponsor's Certification

Part 3. Sponsor's Statement, Contact

Information, Certification, and Signature

NOTE: Read the information on penalties in the Penalties

section of the Form I-865 Instructions before completing this

part.

I can read and understand English, and have read and

understand every question and instruction on this

notice, as well as my answer to every question.

1.a.

Sponsor's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If

applicable, select the box for Item Number 2.

I furthermore authorize release of information contained in this

notice, in supporting documents, and in my USCIS records 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

notice and any document submitted with my notice were

provided by me and are complete, true, and correct.

Sponsor's Signature

Date of Signature (mm/dd/yyyy)6.b.

Sponsor's Signature6.a.

NOTE TO ALL SPONSORS: If you do not completely fill

out this notice or fail to submit required documents listed in the

Instructions, USCIS may reject your notice.

Page 3 of 5Form I-865 07/17/15 N

Interpreter's Certification

I have read to this sponsor every question and instruction on

this notice, as well as the answer to every question, in the

language provided in Part 3., Item Number 1.b.; and

I certify that:

which is the same language provided in Part 3., Item Number

1.b.;

I am fluent in English and

The sponsor has informed me that he or she understands every

instruction and question on the notice, as well as the answer to

every question, and the sponsor verified the accuracy of every

answer.

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

Interpreter's Mailing Address

3.h.

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f.

3.g.

Province

Street Number

and Name

3.a.

Country

3.b. Apt.

Flr.Ste.

Postal Code

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)5.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)6.b.

Interpreter's Signature6.a.

Preparer's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

Street Number

and Name

3.a.

3.b. Apt.

Flr.Ste.

3.h.

3.f.

Postal Code 3.g.

Country

Province

Part 5. Contact Information, Statement,

Certification, and Signature of the Person

Preparing this Notice, If Other Than the Sponsor

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.

Provide the following information about the preparer.

Preparer's Contact Information

6. Preparer's Email Address (if any)

4. Preparer's Daytime Telephone Number

5. Preparer's Fax Number

Page 4 of 5Form I-865 07/17/15 N

I am not an attorney or accredited representative

but have prepared this notice on behalf of the

sponsor and with the sponsor's consent.

I am an attorney or accredited representative and

my representation of the sponsor in this case

7.a.

7.b.

Preparer's Statement

extends does not extend beyond the

preparation of this notice.

NOTE: If you are an attorney or accredited

representative whose representation extends

beyond preparation of this notice, you must

submit a completed Form G-28, Notice of Entry

of Appearance as Attorney or Accredited

Representative, with this notice.

By my signature, I certify, swear, or affirm, under penalty of

perjury, that I prepared this notice on behalf of, at the request

of, and with the express consent of the sponsor. I completed

this notice based only on responses the sponsor provided to me.

After completing the notice, I reviewed it and all of the

sponsor's responses with the sponsor, who agreed with every

answer on the notice. If the sponsor supplied additional

information concerning a question on the notice, I recorded it on

the notice.

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Preparer's Certification

Preparer's Signature

Part 5. Contact Information, Statement,

Certification, and Signature of the Person

Preparing this Notice, If Other Than the Sponsor

(continued)

Page 5 of 5Form I-865 07/17/15 N

Part 6.

Additional Information

If you need extra space to provide any additional information

within this notice, 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 notice or attach a separate sheet of

paper. Include your name 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.b.

1.c.

1.a. Family Name

(Last Name)

Given Name

(First Name)

Middle Name

3.d.

3.a.

Page Number

3.b.

Part Number

3.c.

Item Number

Page Number Part Number Item Number

5.d.

5.a.

Page Number

5.b.

Part Number

5.c.

Item Number

6.d.

6.a.

Page Number

6.b.

Part Number

6.c.

Item Number

Page Number Part Number Item Number

4.c.4.b.

4.d.

4.a.

2.c.2.b.2.a.

2.d.