Form I-865, Sponsor'S Notice Of Change Of Address - Department Of Homeland Security
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2OMB No. 1615-0076; Expires 01/31/2015
Form I-865, Sponsor's Notice
Department of Homeland Security
of Change of Address
U.S. Citizenship and Immigration Services
START HERE-Type or print in black ink
For USCIS Use Only
Part 1. Information About You, the Sponsor
Returned
Receipt
Family Name
Given Name
Middle Name
Date
Date
Date of Birth (mm/dd/yyyy)
Place of Birth (City, State/Province /Country)
Resubmitted
A-Number (if any)
U.S. Social Security Number
Date
Date
Your current status (Check one)
I am a
U.S. Citizen
Lawful Permanent Resident
Action Block
NOTE: If you became a U.S. citizen following the filing of your Form I-864, Affidavit
of Support, or submission of a prior Form I-865 address change, include a copy of proof
of your U.S. citizenship (example: naturalization certificate, certificate of citizenship,
U.S. passport) with this notice.
Your New Home Address - Street Number and Name (Include Apt. # if applicable)
City
State or Province
Zip/Postal Code
Country
Effective Date of Change of Address
Daytime Telephone (Area/Country Code)
E-Mail Address (if any)
Remarks
Your New Mailing Address - NOTE: You do not need to complete this section if your
new mailing address is the same as your new home address above.
Street Number and Name (Include Apt.#, if applicable)
C/O (in care of):
City
State or Province
Zip/Postal Code
Effective Date of Change of Address
Daytime Telephone (Area/Country Code)
E-Mail Address (if any)
Part 2. Information on Sponsored Immigrant(s) (If more than one person, attach a separate sheet(s) of paper)
Provide the requested information on the person(s) your are sponsoring:.
Family Name
Given Name
Middle Name
A-Number
Form I-865 01/03/13 Y Page 1
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