Form I-864ez - Affidavit Of Support Under Section 213a Of The Act Page 2
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7Military Service
Part 3. Information About You (Sponsor)
(continued)
I am currently on active duty in the United States Armed
13.
Forces or U.S. Coast Guard.
Yes
No
3.
Is your current mailing address the same as your physical
address?
Yes
No
Part 4. Information About Your Household Size
If you answered "No" to Item Number 3., provide your
physical address below.
NOTE: Do not count any household member more than once.
1.a. Yourself and the person you are sponsoring on this Form
Physical Address
I-864EZ.
4.a.
Street Number
and Name
1.b.
Your spouse.
4.b.
Apt.
Ste.
Flr.
1.c.
Your dependent children under 21 years of age.
4.c. City or Town
1.d.
If you have sponsored any other persons on a Form I-864
who are now lawful permanent residents in the United
4.d. State
4.e. ZIP Code
States, enter the number here.
4.f.
Province
1.e.
If you have any other dependents listed on your most
recent Federal income tax return, enter the number here.
4.g.
Postal Code
4.h.
Country
1.f.
Add together Item Numbers 1.a. - 1.e. and enter the
number here. This is your HOUSEHOLD SIZE for the
purpose of this Form I-864EZ.
Other Information
5.
Country of Domicile
Part 5. Information About Your Employment
and Income
6.
Date of Birth (mm/dd/yyyy)
1.
I am currently:
7.
City or Town of Birth
Employed (Complete Item Numbers 2.a. - 2.c.)
Retired (Complete Item Numbers 3.a. - 3.b.)
8.
State or Province of Birth (if applicable)
2.a.
Current Occupation
9.
Country of Birth
2.b.
Name of Employer 1 (if applicable)
10.
U.S. Social Security Number (Required)
2.c.
Name of Employer 2 (if applicable)
►
11.
USCIS ELIS Account Number (if any)
3.a.
Name of Former Employer
►
Citizenship or Nationality
3.b.
Date of Retirement (mm/dd/yyyy)
12.a.
I am a U.S. citizen.
4.
My current individual annual income
$
12.b.
I am a lawful permanent resident.
12.c.
My alien registration number is:
►
A-
12.d.
I am a U.S. national.
Form I-864EZ 07/02/15 N
Page 2 of 7
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