Form I-864ez - Affidavit Of Support Under Section 213a Of The Act Page 4
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7Sponsor's Statement
Part 6. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b.
(continued)
If applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and have read and
What If I Do Not Fulfill My Obligations?
understand every question and instruction on this
affidavit, as well as my answer to every question.
If you do not provide sufficient support to the person who
becomes a lawful permanent resident based on the Form
1.b.
The interpreter named in Part 7. has also read to me
I-864EZ that you signed, that person may sue you for this
every question and instruction on this affidavit, as
support.
well as my answer to every question, in
If a Federal, state, local, or a private agency provides any covered
,
means-tested public benefit to the person who becomes a lawful
a language in which I am fluent. I understand every
permanent resident based on the Form I-864EZ that you signed,
question and instruction on this affidavit as translated
the agency may ask you to reimburse them for the amount of the
to me by my interpreter, and have provided complete,
benefits they provided. If you do not make the reimbursement,
true, and correct responses in the language indicated
the agency may sue you for the amount that the agency believes
above.
you owe.
I have requested the services of and consented to
2.
If you are sued, and the court enters a judgment against you, the
,
person or agency that sued you may use any legally permitted
who
is
is not an attorney or accredited
procedures for enforcing or collecting the judgment. You may
representative, preparing this affidavit for me.
also be required to pay the costs of collection, including attorney
fees.
Sponsor's Contact Information
If you do not file a properly completed Form I-865 within 30
days of any change of address, USCIS may impose a civil fine
Sponsor's Daytime Telephone Number
3.
for your failing to do so. Please see the USCIS Web site at
for more information on filing a change
of address as a sponsor.
Sponsor's Mobile Telephone Number (if any)
4.
When Will These Obligations End?
5.
Sponsor's Email Address (if any)
Your obligations under Form I-864EZ will end if the person
who becomes a lawful permanent resident based on a Form
I-864EZ that you signed:
Sponsor's Certification
A.
Becomes a U.S. citizen;
Copies of any documents I have submitted are exact
B.
Has worked, or can receive credit for 40 quarters of
photocopies of unaltered, original documents, and I understand
coverage under the Social Security Act (SSA);
that USCIS or the Department of State may require that I submit
C.
No longer has lawful permanent resident status and
original documents to USCIS or the Department of State at a
has departed the United States;
later date. Furthermore, I authorize the release of any
information from any and all of my records that USCIS or the
D.
Becomes subject to removal, but applies for and
Department of State may need to determine my eligibility for
obtains in removal proceedings a new grant of
the immigration benefit that I seek.
adjustment of status, based on a new affidavit of
support, if one is required; or
I furthermore authorize release of information contained in this
affidavit, in supporting documents, and in my USCIS or
E.
Dies.
Department of State records to other entities and persons where
necessary for the administration of U.S. immigration laws.
NOTE: Divorce does not terminate your obligations
under this Form I-864EZ.
I certify, under penalty of perjury, that the information in my
affidavit and any document submitted with my affidavit were
Your obligations under Form I-864EZ also end if you die.
provided by me and are complete, true, and correct, and:
Therefore, if you die, your estate will not be required to take
responsibility for the person's support after your death. Your
estate may, however, be responsible for any support that you
owed before you died.
Form I-864EZ 07/02/15 N
Page 4 of 7
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