Form I-864 - Affidavit Of Support Under Section 213a Of The Act Page 5
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16OMB No. 1115-0214
Affidavit of Support Under Section
U.S. Department of Justice
213A of the Act
Immigration and Naturalization Service
START HERE - Please Type or Print
Part 1.
Information on Sponsor (You)
Last Name
First Name
Middle Name
Mailing Address (Street Number and Name)
Apt/Suite Number
State or Province
City
Country
ZIP/Postal Code
Telephone Number
Place of Residence if different from above (Street Number and Name)
Apt/Suite Number
FOR AGENCY USE ONLY
This Affidavit
Receipt
City
State or Province
[ ] Meets
Country
ZIP/Postal Code
Telephone Number
[ ] Does not
meet
Date of Birth (Month, Day, Year)
Place of Birth (City, State, Country)
Are you a U.S. Citizen?
Requirements of
Yes
No
Section 213A
Social Security Number
A-Number (If any)
Part 2.
Basis for Filing Affidavit of Support
Officer or I.J.
:
I am filing this affidavit of support because (check one)
Signature
a.
I filed/am filing the alien relative petition.
b.
I filed/am filing an alien worker petition on behalf of the intending
Location
.
immigrant, who is related to me as my
(relationship)
.
c.
I have ownership interest of at least 5%
Date
(name of entity which filed visa petition)
which filed an alien worker petition on behalf of the intending
.
immigrant, who is related to me as my
(relationship)
d.
I am a joint sponsor willing to accept the legal obligations with any other sponsor(s).
Part 3.
Information on the Immigrant(s) You Are Sponsoring
Last Name
First Name
Middle Name
Date of Birth (Month,Day, Year)
Sex
Social Security Number (If any)
Male
Female
Country of Citizenship
A-Number (If any)
Current Address
(Street Number and Name)
Apt/Suite Number
City
State/Province
Country
ZIP/Postal Code
Telephone Number
(Use additional sheet of paper if necessary.)
List any spouse and/or children immigrating with the immigrant named above in this Part:
Relationship to Sponsored
Immigrant
Date of Birth
A-Number
Social Security
Name
(If any)
(If any)
Spouse
Son
Daughter
Mo.
Day
Yr.
Form I-864 (Rev. 11/05/01)Y
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