Request for Exemption for Intending Immigrant's Affidavit of Support Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-864W OMB No. 1615-0075 Expires 07/31/2017 For Government Use Only This Form I-864W: DOES NOT MEET the requirements of exemption MEETS the requirements of exemption Reviewed By: Location: Date (mm/dd/yyyy): START HERE - Type or print in black ink. Part 1. Information About You or Your Adopted Child (Intending Immigrant) Name of Requestor 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Physical Address 4.a. Street Number and Name 4.b Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.f. Province 4.e. ZIP Code Mailing Address 2.a. In Care Of Name 4.g. Postal Code 4.h. Country 2.b. Street Number and Name 2.c. Apt. Ste. Flr. Other Information 5. 6. 2.f. ZIP Code 7. State or Province of Birth (if applicable) Date of Birth (mm/dd/yyyy) City or Town of Birth 2.d. City or Town 2.e. State 2.g. Province 2.h. Postal Code 2.i. Country 8. Country of Birth 9. 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. 11. Alien Registration Number (A-Number) (if any) A- 10. USCIS ELIS Account Number (if any) U.S. Social Security Number (if any) Form I-864W 07/02/15 N Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Reason for Exemption I am EXEMPT from filing Form I-864, Affidavit of Support Under Section 213A of the INA, because: 1.a. 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 years of age, 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, Petition for Amerasian, Widow(er), or Special Immigrant. I am filing for an immigrant visa or adjustment of status as a battered spouse or child using Form I-360. Requestor's Contact Information 3. Requestor's Daytime Telephone Number 4. Requestor's Mobile Telephone Number (if any) 5. Requestor's Email Address (if any) 1.b. Requestor's Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS or the Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS or the Department of State may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this request, in supporting documents, and in my USCIS or the Department of State record to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I certify, under penalty of perjury, that the information in my request and any document submitted with my request were provided by me and are complete, true, and correct. In addition, I authorize the Social Security Administration (SSA) to release information about me in its records to the Department of State and U.S. Citizenship and Immigration Services. 1.c. 1.d. Part 3. Requestor's (Intending Immigrant's) Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-864W Instructions before completing this part. Requestor's Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and have read and understand every question and instruction on this request, as well as my answer to every question. The interpreter named in Part 4. has also read to me every question and instruction on this request, as well as my answer to every question, in , a language in which I am fluent. I understand every question and instruction on this request as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. 2. I have requested the services of and consented to , who is is not an attorney or accredited representative, preparing this request for me. Requestor's Signature 6.a. Requestor's Signature (or U.S. citizen parent, if intending immigrant is less than 14 years of age) 1.b. 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the instructions, USCIS or the Department of State may deny your request. Form I-864W 07/02/15 N Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Signature 6.a. Interpreter's Signature Interpreter's Full Name 1.a. Interpreter's Family Name (Last Name) 6.b. Date of Signature (mm/dd/yyyy) 1.b. Interpreter's Given Name (First Name) Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this Request, If Other than the Requestor Provide the following information about the preparer. 2. Interpreter's Business or Organization Name (if any) Preparer's Full Name Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 1.b. Preparer's Given Name (First Name) 1.a. Preparer's Family Name (Last Name) 3.c. City or Town 3.d. State 3.f. Province 3.e. ZIP Code 2. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.g. Postal Code 3.h. Country 3.c. City or Town Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 3.d. State 3.f. 5. Interpreter's Email Address (if any) Province 3.e. ZIP Code 3.g. Postal Code 3.h. Country Interpreter's Certification I certify that: , I am fluent in English and which is the same language provided in Part 3., Item Number 1.b.; I have read to this requestor every question and instruction on this request, as well as the answer to every question, in the language provided in Part 3., Item Number 1.b.; and The requestor has informed me that he or sh