Form I-865 - Sponsor'S Notice Of Change Of Address Page 4
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5OMB No. 1615-0076; Expires 10/31/2012
I-865, Sponsor's Notice
Department of Homeland Security
of Change of Address
U.S. Citizenship and Immigration Services
START HERE-Type or print in black ink
For USCIS Use Only
Receipt
Returned
Part 1. Information About You, the Sponsor
Date
Family Name
Given Name
Middle Name
Date of Birth (mm/dd/yyyy)
Place of Birth (City, State/Province /Country)
Resubmitted
Date
A-Number (if any)
U.S. Social Security Number
Date
Your current status- (Check one)
Action Block
I am a
U.S. Citizen
Lawful Permanent Resident
NOTE: If you became a U.S. citizen following the filing of your Form I-864, Affidavit
of Support, or submission of a prior Form I-865 address change, include a copy of proof
of your U.S. citizenship (example: naturalization certificate, certificate of citizenship,
U.S. passport) with this notice.
Your New Home Address - Street Number and Name (Include Apt. # if applicable)
City
State or Province
Zip/Postal Code
Country
Daytime Telephone (Area/Country Code)
Effective Date of Change of Address
E-Mail Address (if any)
Remarks
Your New Mailing Address - NOTE: You do not need to complete this section if your
new mailing address is the same as your new home address above.
Street Number and Name (Include Apt.#, if applicable)
C/O (in care of):
City
State or Province
Zip/Postal Code
Effective Date of Change of Address
Daytime Telephone (Area/Country Code)
E-Mail Address (if any)
Part 2. Information on Sponsored Immigrant(s)
(If more than one person, continue this part on a separate sheet(s) of paper)
Provide the requested information on the person(s) your are sponsoring:.
Family Name
Given Name
Middle Name
A-Number
Form I-865 (Rev. 10/26/10)Y
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