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Form I-864w - Intending Immigrant'S Affidavit Of Support Exemption And Instrtuctions Page 3

OMB No. 1615-0075; Expires 10/31/10

I-864W, Intending Immigrant's

Department of Homeland Security

Affidavit of Support Exemption

U.S. Citizenship and Immigration Services

Part 1. Information about the intending immigrant. (You or your adopted child.)

For Government

Last Name

1. Name

Use Only

First Name

Middle Name

This I-864W:

Street Number and Name (include apartment number)

2. Address

does not meet the

requirements of

City

State or Province

exemption.

Country

Zip/Postal Code

meets the

3. Date of Birth

requirements of

(mm/dd/yyyy)

exemption.

Country of Birth

(city/country)

5. Telephone Number

(Include area code or country and city codes)

Reviewer

6. Social Security

Location

Number (if any)

7. Alien Registration

Number (if any)

Date (mm/dd/yyyy)

Part 2. Reason for exemption.

I am EXEMPT from filing a Form I-864 Affidavit of Support because:

I have earned (or can be credited with) 40 quarters (credits) of coverage under the Social

Security Act (SSA). (Attach SSA earnings statements. Do not count any quarters during

which you received a means-tested public benefit.)

I am under 18, unmarried, immigrating as the child of a U.S. citizen, and will automatically

become a U.S. citizen under the Child Citizenship Act of 2000 upon my admission to the

United States.

I am filing for an immigrant visa or adjustment of status as a self-petitioning widow(er)

using Form I-360.

I am filing for an immigrant visa or adjustment of status as a battered spouse or child using

Form I-360.

Part 3. Concluding provision.

, certify under penalty

of perjury under the laws of the United States that:

(a) I know the contents of this exemption request which I signed;

(b) All the statements in this exemption request are true and correct; and

records to the Department of State and U.S. Citizenship and Immigration Services.

(Signature of intending immigrant, or of U.S. citizen parent

(Date--mm/dd/yyyy)

if intending immigrant is less than 14 years old)

Form I-864W (Rev. 10/18/07)Y

Form I-864w - Intending Immigrant'S Affidavit Of Support Exemption And Instrtuctions Page 3

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