Form I-864 - Affidavit Of Support Under Section 213a Of The Act Page 16
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16OMB No. 1115-0215
U.S. Department of Justice
Sponsor's Notice of Change of Address
Immigration and Naturalization Service
START HERE - Please Type or Print
Answer all Questions
Part 1.
Information about Sponsor
Last Name
First Name
Middle Name
Date of Birth (Month, Day, Year)
Place of Birth (City, State, Country)
A-Number (If any)
Social Security Number
My New Mailing Address
(Street Number and Name)
Apt/Suite Number
FOR AGENCY USE ONLY
Receipt
City
State or Province
Country
ZIP/Postal Code
Telephone Number
My New Place of Residence if different from above (Street Number and Name)
Apt/Suite Number
City
State or Province
Country
Telephone Number
ZIP/Postal Code
Effective Date of Change of Address
Part 2.
Sponsor's Signature
I certify under penalty of perjury under the laws of the United States of America that all information on this notice is true and correct.
Signature
Daytime Telephone
Date
Part 3.
Signature of person preparing notice if other than sponsor
I declare I prepared this application at the request of the above person and it is based on information of which I have knowledge.
Date
Daytime Telephone
Signature
First name
Middle Initial
Last Name (Print)
Firm Name and Address (Print)
Public Reporting Burden
Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be
easily understood, and which impose the least possible burden on you to provide us with information. Often this is difficult because
some immigration laws are very complex. The estimated average time to complete and file this form is 15 minutes. If you have
comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Immigration and
Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536, OMB No.1115-0215. DO NOT MAIL
THIS FORM TO THIS ADDRESS.
Form I-865 (09/18/00)Y
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