Form I-864w - Request For Exemption For Intending Immigrant'S Affidavit Of Support
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5Request for Exemption for
USCIS
Intending Immigrant's Affidavit of Support
Form I-864W
Department of Homeland Security
OMB No. 1615-0075
U.S. Citizenship and Immigration Services
Expires 07/31/2017
For Government Use Only
This Form I-864W:
DOES NOT MEET
MEETS the
Reviewed By:
the requirements of
requirements
Location:
Date (mm/dd/yyyy):
exemption
of exemption
►
START HERE - Type or print in black ink.
Physical Address
Part 1. Information About You or Your Adopted
Child (Intending Immigrant)
4.a.
Street Number
and Name
Name of Requestor
4.b
Apt.
Ste.
Flr.
1.a. Family Name
(Last Name)
4.c. City or Town
1.b. Given Name
(First Name)
4.d. State
4.e. ZIP Code
1.c. Middle Name
4.f.
Province
Mailing Address
4.g. Postal Code
2.a. In Care Of Name
4.h. Country
2.b.
Street Number
Other Information
and Name
2.c.
Apt.
Ste.
Flr.
5.
Date of Birth (mm/dd/yyyy)
2.d. City or Town
6.
City or Town of Birth
2.e. State
2.f.
ZIP Code
7.
State or Province of Birth (if applicable)
2.g. Province
2.h. Postal Code
8.
Country of Birth
2.i.
Country
9.
Alien Registration Number (A-Number) (if any)
►
A-
3.
Is your current mailing address the same as your physical
address?
Yes
No
10.
USCIS ELIS Account Number (if any)
►
If you answered "No" to Item Number 3., provide your
physical address.
11.
U.S. Social Security Number (if any)
►
Form I-864W 07/02/15 N
Page 1 of 5
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