Form I-864w - Request For Exemption For Intending Immigrant'S Affidavit Of Support Page 2
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5Part 2. Reason for Exemption
Requestor's Contact Information
3.
Requestor's Daytime Telephone Number
I am EXEMPT from filing Form I-864, Affidavit of Support
Under Section 213A of the INA, because:
1.a.
I have earned (or can be credited with) 40 quarters
4.
Requestor's Mobile Telephone Number (if any)
(credits) of coverage under the Social Security Act
(SSA). (Attach SSA earnings statements. Do not
count any quarters during which you received a
5.
Requestor's Email Address (if any)
means-tested public benefit.)
1.b.
I am under 18 years of age, unmarried, immigrating
as the child of a U.S. citizen, and will automatically
Requestor's Certification
become a U.S. citizen under the Child Citizenship
Act of 2000 upon my admission to the United States.
Copies of any documents I have submitted are exact
1.c.
I am filing for an immigrant visa or adjustment of
photocopies of unaltered, original documents, and I understand
status as a self-petitioning widow(er) using Form
that USCIS or the Department of State may require that I submit
I-360, Petition for Amerasian, Widow(er), or Special
original documents to USCIS or the Department of State at a
Immigrant.
later date. Furthermore, I authorize the release of any
information from any and all of my records that USCIS or the
1.d.
I am filing for an immigrant visa or adjustment of
Department of State may need to determine my eligibility for
status as a battered spouse or child using Form I-360.
the immigration benefit that I seek.
I furthermore authorize release of information contained in this
Part 3. Requestor's (Intending Immigrant's)
request, in supporting documents, and in my USCIS or the
Statement, Contact Information, Certification,
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
and Signature
immigration laws.
NOTE: Read the information on penalties in the Penalties
I certify, under penalty of perjury, that the information in my
section of the Form I-864W Instructions before completing this
request and any document submitted with my request were
part.
provided by me and are complete, true, and correct.
In addition, I authorize the Social Security Administration (SSA)
Requestor's Statement
to release information about me in its records to the Department
NOTE: Select the box for either Item Number 1.a. or 1.b.
of State and U.S. Citizenship and Immigration Services.
If applicable, select the box for Item Number 2.
Requestor's Signature
1.a.
I can read and understand English, and have read and
understand every question and instruction on this
6.a.
Requestor's Signature (or U.S. citizen parent, if intending
request, as well as my answer to every question.
immigrant is less than 14 years of age)
1.b.
The interpreter named in Part 4. has also read to me
every question and instruction on this request, as well
as my answer to every question, in
6.b.
Date of Signature (mm/dd/yyyy)
,
NOTE TO ALL REQUESTORS: If you do not completely
a language in which I am fluent. I understand every
fill out this request or fail to submit required documents listed
question and instruction on this request as translated
in the instructions, USCIS or the Department of State may deny
to me by my interpreter, and have provided complete,
your request.
true, and correct responses in the language indicated
above.
I have requested the services of and consented to
2.
,
who
is
is not an attorney or accredited
representative, preparing this request for me.
Form I-864W 07/02/15 N
Page 2 of 5
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