Form I-864 - Affidavit Of Support Under Section 213a Of The Act Page 4
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9For
USCIS
Use
Only
Part 4. Information on the Sponsor (continued)
7.
City or Town of Birth
Citizenship/Residency
11.a.
I am a U.S. citizen.
8.
State or Province of Birth
11.b.
I am a U.S. national (for joint sponsors only).
11.c.
I am a lawful permanent resident.
9.
Country of Birth
My alien registration number is:
►
A-
10.
U.S. Social Security Number (Required)
Military Service (To be completed by petitioner sponsors only.)
►
12.
I am currently on active duty in the U.S. armed services.
Yes
No
Part 5. Sponsor's Household Size
5.
If you have any other dependents, enter the
Your Household Size - DO NOT COUNT ANYONE TWICE
number here.
Persons you are sponsoring in this affidavit:
6.
If you have sponsored any other persons on
1.
Enter the number you entered on line 7 of Part 3.
an I-864 or I-864 EZ who are now lawful
permanent residents, enter the number here.
Persons NOT sponsored in this affidavit:
7.
OPTIONAL: If you have siblings, parents, or
2.
Yourself.
adult children with the same principal
residence who are combining their income
3.
If you are currently married, enter "1" for
with yours by submitting Form I-864A, enter
your spouse.
the number here.
4.
If you have dependent children, enter the
8.
Add together lines 1-7 and enter the number
number here.
here. Household Size:
Part 6. Sponsor's Income and Employment
I am currently:
2.
Self-employed as a/an
1.
Employed as a/an
3.
Retired from:
1.a.
Name of Employer #1 (if applicable)
3.a.
Company Name
1.b.
Name of Employer #2 (if applicable)
3.b.
Date of Retirement
►
(mm/dd/yyyy)
Form I-864 03/22/13 N
Page 4 of 9
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