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Get I 864 Form 2021-2024

USCIS ELIS Account Number if any If you answered No to Item Number 3. provide your U.S. Social Security Number if any Form I-864W 07/02/15 N Page 1 of 5 Part 2. 1. d. status as a battered spouse or child using Form I-360. NOTE Read the information on penalties in the Penalties section of the Form I-864W Instructions before completing this part. Request for Exemption for Intending Immigrant s Affidavit of Support USCIS Form I-864W Department of Homeland Security U.S. Citizenship and Immigration Services OMB No. 1615-0075 Expires 07/31/2017 For Government Use Only DOES NOT MEET the requirements of exemption MEETS the 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 Physical Address 4. a* Street Number and Name 4. b 1. a* Family Name Last Name 1. b. Given Name First Name Apt. Ste. Flr. 4. c* City or Town 4. d. State 1. c* Middle Name 4. f* 4. e. ZIP Code Province Mailing Address 4. g. Postal Code 2. a* In Care Of Name 4. h. Country 2. b. Street Number Other Information 2. c* State or Province of Birth if applicable Country of Birth 2. f* City or Town of Birth 2. e. State Date of Birth mm/dd/yyyy 2. d. City or Town Alien Registration Number A-Number if any ZIP Code 2. g. Province 2. i. Country Is your current mailing address the same as your physical address Yes No A10. Reason for Exemption Requestor s Contact Information I am EXEMPT from filing Form I-864 Affidavit of Support Under Section 213A of the INA because Requestor s Daytime Telephone Number Requestor s Mobile Telephone Number if any Requestor s Email Address if any 1. a* 1. b. 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. 1. c* 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. NOTE Select the box for either Item Number 1. a* or 1. b. If applicable select the box for Item Number 2. 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. 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.

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