I-864w, Intending Immigrants Affidavit Of Support Exemption Page 3
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3OMB No. 1615-0075; Expires 09/30/2012
I-864W, Intending Immigrant's
Department of Homeland Security
Affidavit of Support Exemption
U.S. Citizenship and Immigration Services
Part 1. Information about the intending immigrant. (You or your adopted child.)
Last Name
1. Name
For Government
Use Only
First Name
Middle Name
This I-864W:
Street Number and Name (include apartment number)
2. Address
does not meet the
requirements of
City
State or Province
exemption.
Country
Zip/Postal Code
meets the
3. Date of Birth
requirements of
(mm/dd/yyyy)
exemption.
4.
Country of Birth
(city/country)
5. Telephone Number
(Include area code or country and city codes)
Reviewer
6. Social Security
Location
Number (if any)
7. Alien Registration
Number (if any)
Date (mm/dd/yyyy)
Part 2. Reason for exemption.
I am EXEMPT from filing a Form I-864 Affidavit of Support 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, 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.
I am filing for an immigrant visa or adjustment of status as a battered spouse or child using
Form I-360.
Part 3. Concluding provision.
I,
, certify under penalty
of perjury under the laws of the United States that:
(a) I know the contents of this exemption request which I signed;
(b) All the statements in this exemption request are true and correct; and
(c) I authorize the Social Security Administration to release information about me in its
records to the Department of State and U.S. Citizenship and Immigration Services.
(Signature of intending immigrant, or of U.S. citizen parent
(Date--mm/dd/yyyy)
if intending immigrant is less than 14 years old)
Form I-864W (09/19/11) Y
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