Form I-864ez - Affidavit Of Support Under Section 213a Of The Act Page 9
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11Part 5. Sponsor's income and employment.
17. I am currently:
For Government
Use Only
.
a.
Employed as a/an
.
Name of Employer (if applicable)
.
Name of Second Employer (if applicable)
b.
Retired since (mm/dd/yyyy)
.
Name of Former Employer
.
$
18. My individual annual income is currently:
19. Federal income tax information.
I have filed a Federal tax return for each of the three most recent tax years. I have attached the
required photocopy or transcript of my Federal tax return for only the most recent tax year.
My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal tax
returns for the most recent three years was:
Tax Year
Total Income
(most recent)
$
(2nd most recent)
$
(3rd most recent)
$
(Optional) I have attached photocopies or transcripts of my Federal tax returns for my second
and third most recent tax years.
Part 6. Sponsor's Contract.
Please note that, by signing this Form I-864EZ, you agree to assume certain specific obligations under the Immigration
and Nationality Act and other Federal laws. The following paragraphs describe those obligations. Please read the
following information carefully before you sign the Form I-864EZ. If you do not understand the obligations, you may wish
to consult an attorney or accredited representative.
What Is the Legal Effect of My Signing a Form I-864EZ?
If you sign a Form I-864EZ on behalf of any person (called the "intending immigrant") who is applying for an immigrant
visa or for adjustment of status to a permanent resident, and that intending immigrant submits the Form I-864EZ to the
U.S. Government with his or her application for an immigrant visa or adjustment of status, under section 213A of the
Immigration and Nationality Act these actions create a contract between you and the U. S. Government. The intending
immigrant's becoming a permanent resident is the "consideration" for the contract.
Under this contract, you agree that, in deciding whether the intending immigrant can establish that he or she is not
inadmissible to the United States as an alien likely to become a public charge, the U.S. Government can consider your
income and assets to be available for the support of the intending immigrant.
Form I-864EZ (09/19/11) Y Page 3
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