Affidavit Support Sample Form
Affidavit of Support Under Section 213A of the Act
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-864
OMB No. 1615-0075
Expires 03/31/2015
START HERE - Type or print in black ink.►
Form I-864 03/22/13 N
Page 1 of 9
Part 1. Basis For Filing Affidavit of Support
am the sponsor submitting this affidavit of support because
(Check only one box):
I am the petitioner. I filed or am filing for the
immigration of my relative.
I filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my
1.c.
1.d.
I have an ownership interest of at least 5 percent in
I am the only joint sponsor.
1.e.
1.f.
I am the
The original petitioner is deceased. I am the
substitute sponsor. I am the intending immigrant's
first second of two joint sponsors.
which filed an alien worker petition on behalf of the
intending immigrant, who is related to me as my
1.b.
1.
1.a.
Part 2. Information on the Principal Immigrant
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Mailing Address
2.c. City or Town
2.d.
State
2.e.
Zip Code
Country2.h.
3. Country of Citizenship
Other Information
►(mm/dd/yyyy)Date of Birth 4.
2.f.
Postal Code
Province2.g.
Alien Registration Number (A-Number)5.
Street Number
and Name
2.a.
NOTE: If you check box 1.b., 1.c., 1.d., 1.e., or 1.f., you must
include proof of your citizen, national, or lawful permanent
resident status.
►
A-
2.b.
Apt.
Flr.Ste.
Affidavit of Support Submitter
Petitioner
1st Joint Sponsor
2nd Joint Sponsor
For
USCIS
Use
Only
Remarks
Date:
Reviewed By:
Office:
Substitute Sponsor
5% Owner
Section 213A Review
MEETS
requirements
DOES NOT MEET
requirements
M M D D Y Y Y Y
/ /
Number of Support Affidavits in File
1
2
Page 1/9
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Affidavit Support Sample Form PDF
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