Affidavit of Support Under Section 213A of the INA Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-864EZ OMB No. 1615-0075 Expires 07/31/2017 For Government Use Only This Form I-864EZ: DOES NOT MEET the requirements of INA section 213A MEETS the requirements of INA section 213A Reviewed By: Location: Date (mm/dd/yyyy): START HERE. Type or print in black ink. Part 1. Qualifying to Use Form I-864EZ 1.a. I am the petitioner of the family member sponsored on this affidavit. Yes No (Use Form I-864) 1.b. I am using my own earned or retirement income, which is documented using Internal Revenue Service (IRS) Form W-2. Yes No (Use Form I-864) 1.c. The sponsored immigrant is the only person immigrating based on the underlying visa petition. Yes No (Use Form I-864) Other Information 3. Daytime Telephone Number 4. 5. Date of Birth (mm/dd/yyyy) Alien Registration Number (A-Number) (if any) AUSCIS ELIS Account Number (if any) U.S. Social Security Number (if any) 6. 7. Part 2. Information About the Immigrant You Are Sponsoring (Intending Immigrant) Name of Immigrant 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Part 3. Information About You (Sponsor) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Mailing Address 2.a. In Care Of Name Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.g. Province 2.h. Postal Code 2.i. Country 2.f. ZIP Code 2.d. City or Town 2.e. State 2.g. Province 2.h. Postal Code 2.i. Country 2.f. ZIP Code Form I-864EZ 07/02/15 N Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information About You (Sponsor) (continued) 3. Is your current mailing address the same as your physical address? Yes No If you answered "No" to Item Number 3., provide your physical address below. Military Service 13. I am currently on active duty in the United States Armed Forces or U.S. Coast Guard. Yes No Part 4. Information About Your Household Size NOTE: Do not count any household member more than once. 1.a. Yourself and the person you are sponsoring on this Form I-864EZ. 1.b. Your spouse. Physical Address 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 1.c. Your dependent children under 21 years of age. 4.c. City or Town 4.d. State 4.f. Province 4.e. ZIP Code 1.d. If you have sponsored any other persons on a Form I-864 who are now lawful permanent residents in the United States, enter the number here. 1.e. If you have any other dependents listed on your most recent Federal income tax return, enter the number here. 4.g. Postal Code 4.h. Country 1.f. Add together Item Numbers 1.a. - 1.e. and enter the number here. This is your HOUSEHOLD SIZE for the purpose of this Form I-864EZ. Other Information 5. Country of Domicile Part 5. Information About Your Employment and Income 6. 7. Date of Birth (mm/dd/yyyy) City or Town of Birth 1. I am currently: Employed (Complete Item Numbers 2.a. - 2.c.) Retired (Complete Item Numbers 3.a. - 3.b.) 8. State or Province of Birth (if applicable) 2.a. Current Occupation 9. Country of Birth 2.b. Name of Employer 1 (if applicable) 10. U.S. Social Security Number (Required) USCIS ELIS Account Number (if any) 2.c. Name of Employer 2 (if applicable) 11. 3.a. Name of Former Employer Citizenship or Nationality 12.a. 12.b. I am a U.S. citizen. I am a lawful permanent resident. 3.b. Date of Retirement (mm/dd/yyyy) 4. My current individual annual income $ 12.c. My alien registration number is: A12.d. I am a U.S. national. Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form I-864EZ 07/02/15 N Part 5. Information About Your Employment and Income (continued) Federal Income Tax Information 5.a. Have you filed a Federal income tax return for each of the three most recent tax years? Yes No NOTE: You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year. 5.b. (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third most recent tax years. 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 a foreign national likely to become a public charge, the U.S. Government can consider your income and assets available for the support of the intending immigrant. What If I Choose Not to Sign Form I-864EZ? You cannot be made to sign Form I-864EZ if you do not want to do so. But if you do not sign Form I-864EZ, the intending immigrant may not be able to become a lawful permanent resident in the United States. My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal income tax returns for the most recent three years was: Tax Year 6.a. Most Recent 6.b. 2nd Most Recent 6.c. 3rd Most Recent $ $ $ Total Income What Does Signing Form I-864EZ Require Me to Do? If an intending immigrant becomes a lawful permanent resident in the United States based on a Form I-864EZ that you have signed, then, until your obligations under Form I-864EZ terminate, you must: A. Provide the intending immigrant any support necessary to maintain him or her at an income that is at least 125 percent of the Federal Poverty Guidelines for his or her household size (or 100 percent if you are the petitioning sponsor and are on active duty in the U.S. Armed Forces or U.S. Coast Guard and the person is your husband, wife, or unmarried child under 21 years of age.) Notify U.S. Citizenship and Immigration Services (USCIS) of any change in your address, within 30 days of the change, by filing Form I-865. Please see the USCIS Web site at www.uscis.gov/I-865 for more information on filing a change of address as a sponsor. Part 6. Sponsor's Contract, Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-864EZ Instructions before completing this part. By signing this Form I-864EZ, you agree to assume certain specific obligations under the Immigration and Nationality Act (INA) and other Federal laws. The following paragraphs describe those obligations. Please read the following information carefully before you sign Form I-864EZ. If you do not understand the obligations, you may wish to consult an attorney or accredited representative. B. What Other Consequences Are There? If an intending immigrant