Sponsor's Notice of Change of Address Form
Page 1 of 5Form I-865 07/17/15 N
For
USCIS
Use
Only
Sponsor's Notice of Change of Address
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink.►
USCIS
Form I-865
Action Block
Resubmitted
Remarks
Part 1.
Information About You (Sponsor)
CSID Number:
Date
Date
Returned
Date
Date
Your New Physical Address
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Your Full Name
City or Town3.c.
Street Number
and Name
3.a.
3.b. Apt.
Flr.
Ste.
3.f.
3.h.
Province
Country
3.g.
Postal Code
ZIP Code
3.e.
State
3.d.
Other Information
2. Date of Birth (mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy) (mm/dd/yyyy)
(mm/dd/yyyy)
Effective Date of Change of Address (mm/dd/yyyy)4.
City or Town6.d.
Street Number
and Name
6.b.
6.c. Apt.
Flr.Ste.
6.g.
6.i.
Province
Country
6.h.
Postal Code
ZIP Code
6.f.
State
6.e.
Effective Date of Change of Address (mm/dd/yyyy)7.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Part 2. Information About the Sponsored
Immigrants
Provide the requested information on the persons you are
sponsoring.
In Care Of Name (if any)6.a.
Your New Mailing Address
Is your new physical address the same as your new
mailing address?
5.
NoYes
If you answered "No" to Item Number 5., provide your
new mailing address in Item Numbers 6.a. - 7.
Sponsored Immigrant 1
Alien Registration Number (A-Number) (if any)2.
A-
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