Looking for a Uscis Forms And Templates? Download it for free!

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this request, and the associated evidence, is collected under the

Immigration and Nationality Act, section 101, and in 8 U.S.C. 1182a(4), 1183a, 1184(a), and 1258.

PURPOSE: The primary purpose for providing the requested information on this request is to determine if you have

established eligibility for the immigration benefit for which you are filing. The information will be used principally by an

immigration judge, USCIS, or a Consular Officer to whom it is furnished, to determine an alien’s eligibility for benefits

under the Immigration and Nationality Act, specifically whether he or she has adequate means of financial support and

will not become a public charge. DHS will use the information you provide to grant or deny the immigration benefit you

are seeking.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and

any requested evidence, may delay a final decision in your case or result in denial of your request.

ROUTINE USES: DHS may share the information you provide on this request with other Federal, state, local, and

foreign government agencies and authorized organizations. DHS follows approved routine uses described in the

associated published system of records notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001

- Alien File, Index, and National File Tracking System of Records] which you can find at DHS

may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection

of information, unless it displays a currently valid OMB control number. The public reporting burden for this collection

of information is estimated at 1 hour per response, including the time for reviewing instructions, gathering the required

documentation and information, completing the request, preparing statements, attaching necessary documentation,

and submitting the request. Send comments regarding this burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory

Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No.

1615-0075. Do not mail your completed Form I-864W to this address.

Form I-864W Instructions 07/02/15 N

Page 6 of 6

Instructions For Form I-864w - Request For Exemption For Intending Immigrant'S Affidavit Of Support Page 6