Form I-864ez - Affidavit Of Support Under Section 213a Of The Act Page 3
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7Under this contract, you agree that, in deciding whether the
Part 5. Information About Your Employment
intending immigrant can establish that he or she is not
and Income (continued)
inadmissible to the United States as a foreign national likely to
become a public charge, the U.S. Government can consider
Federal Income Tax Information
your income and assets available for the support of the
intending immigrant.
5.a.
Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No
What If I Choose Not to Sign Form I-864EZ?
NOTE: You MUST attach a photocopy or transcript
You cannot be made to sign Form I-864EZ if you do not want to
of your Federal income tax return for only the most
do so. But if you do not sign Form I-864EZ, the intending
recent tax year.
immigrant may not be able to become a lawful permanent
resident in the United States.
5.b.
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
third most recent tax years.
What Does Signing Form I-864EZ Require Me to
Do?
My total income (adjusted gross income on IRS Form 1040EZ)
If an intending immigrant becomes a lawful permanent resident
as reported on my Federal income tax returns for the most recent
in the United States based on a Form I-864EZ that you have
three years was:
signed, then, until your obligations under Form I-864EZ
Tax Year
Total Income
terminate, you must:
6.a.
Most Recent
$
A.
Provide the intending immigrant any support
6.b. 2nd Most Recent
$
necessary to maintain him or her at an income that is
at least 125 percent of the Federal Poverty
6.c.
3rd Most Recent
$
Guidelines for his or her household size (or 100
percent if you are the petitioning sponsor and are on
active duty in the U.S. Armed Forces or U.S. Coast
Part 6. Sponsor's Contract, Statement, Contact
Guard and the person is your husband, wife, or
Information, Certification, and Signature
unmarried child under 21 years of age.)
B.
Notify U.S. Citizenship and Immigration Services
NOTE: Read the information on penalties in the Penalties
(USCIS) of any change in your address, within 30
section of the Form I-864EZ Instructions before completing this
days of the change, by filing Form I-865. Please
part.
see the USCIS Web site at
for
By signing this Form I-864EZ, you agree to assume certain
more information on filing a change of address as a
specific obligations under the Immigration and Nationality
sponsor.
Act (INA) and other Federal laws. The following paragraphs
describe those obligations. Please read the following
What Other Consequences Are There?
information carefully before you sign Form I-864EZ. If you
do not understand the obligations, you may wish to consult an
If an intending immigrant becomes a lawful permanent resident
attorney or accredited representative.
in the United States based on a Form I-864EZ that you have
signed, then, until your obligations under Form I-864EZ
What Is the Legal Effect of Signing Form
terminate, your income and assets may be considered available
to that person, in determining whether he or she is eligible for
I-864EZ?
certain Federal means-tested public benefits and also for state
If you sign Form I-864EZ on behalf of any person (intending
or local means-tested public benefits, if the state or local
immigrant) who is applying for an immigrant visa or adjustment
government's rules provide for consideration of your income
of status to a lawful permanent resident, and that intending
and assets as available to the person.
immigrant submits Form I-864EZ to the U.S. Government with
This provision does not apply to public benefits specified in
his or her application for an immigrant visa or adjustment of
section 403(c) of the Welfare Reform Act, such as emergency
status, under INA section 213A, these actions create a contract
Medicaid; short-term, non-cash emergency relief; services
between you and the U.S. Government. The intending
provided under the National School Lunch and Child Nutrition
immigrant becoming a lawful permanent resident is the
Acts; immunizations and testing and treatment for
"consideration" for the contract.
communicable diseases; and means-tested programs under the
Elementary and Secondary Education Act.
Form I-864EZ 07/02/15 N
Page 3 of 7
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