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OMB No. 1615-0076 Expires 01/31/2015 Form I-865 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 For USCIS Use Only Part 1. Information About You the Sponsor Family Name Given Name Date of Birth mm/dd/yyyy Returned Middle Name Date Place of Birth City State/Province /Country A-Number if any Resubmitted U*S* Social Security Number Your current status Check one I am a Receipt Lawful Permanent Resident NOTE If you became a U*S* citizen following the filing of your Form I-864 Affidavit of Support or submission of a prior Form I-865 address change include a copy of proof of your U*S* citizenship example naturalization certificate certificate of citizenship U*S* passport with this notice. Action Block Your New Home Address - Street Number and Name Include Apt. if applicable City Zip/Postal Code State or Province Country Effective Date of Change of Address Daytime Telephone Area/Country Code E-Mail Address if any Remarks Your New Mailing Address - NOTE You do not need to complete this section if your new mailing address is the same as your new home address above. Street Number and Name Include Apt. if applicable C/O in care of Provide the requested information on the person s your are sponsoring. A-Number Form I-865 01/03/13 Y Page 1 Part 3. Sponsor s Signature Read the information on penalties in the instructions before completing this part I certify under penalty of perjury under the laws of the United States of America that all the information provided on this notice is true and correct. Signature Date mm/dd/yyyy Part 4. Signature of Person Preparing Form If Other Than Above Sign below I declare that I prepared this request at the request of the above person and it is based on all information of which I have knowledge. Preparer s Signature Preparer s Printed Name Preparer s Firm Name if applicable Preparer s Address Daytime Phone Number with area code. Information About You the Sponsor Family Name Given Name Date of Birth mm/dd/yyyy Returned Middle Name Date Place of Birth City State/Province /Country A-Number if any Resubmitted U*S* Social Security Number Your current status Check one I am a Receipt Lawful Permanent Resident NOTE If you became a U*S* citizen following the filing of your Form I-864 Affidavit of Support or submission of a prior Form I-865 address change include a copy of proof of your U*S* citizenship example naturalization certificate certificate of citizenship U*S* passport with this notice. Action Block Your New Home Address - Street Number and Name Include Apt. if applicable City Zip/Postal Code State or Province Country Effective Date of Change of Address Daytime Telephone Area/Country Code E-Mail Address if any Remarks Your New Mailing Address - NOTE You do not need to complete this section if your new mailing address is the same as your new home address above. Action Block Your New Home Address - Street Number and Name Include Apt. if applicable City Zip/Postal Code State or Province Country Effective Date of Change of Address Daytime Telephone Area/Country Code E-Mail Address if any Remarks Your New Mailing Address - NOTE You do not need to complete this section if your new mailing address is the same as your new home address above. Street Number and Name Include Apt. if applicable C/O in care of Provide the requested information on the person s your are sponsoring.

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