Address (street number and name):

Telephone:

Social Security Number (if any):

Country of citizenship:

A-number (if any):

Current Address (street number and name):

Telephone:

I am:

     1.  Employed by

Annual salary $	or hourly wage $
for hours/week

     2.  Self employed

Nature of employment or business

1. Number of persons (related to you by birth, marriage, or adoption) living in your residence, including yourself (Do NOT include persons being sponsored in this affidavit):


2. Number of immigrants being sponsored in this affidavit:
3. Number of immigrants NOT living in your household whom you are still obligated to support under a previously signed Form I-864:
4. Number of persons who are otherwise dependent on you, as claimed in your tax return for the most recent tax year
5. Total household size (add lined 1 through 4):

List persons who are included in lines 1 or 3 for whom you previously have submitted Form I-864, if your support obligation has not terminated:

Name:

A-Number:

Date Affidavit of Support Signed:

Relationship:

 I filed a single/separate tax return for the most recent tax year.

 I filed a joint return for the most recent tax year which includes only my own income.

 I filed a joint return for the most recent tax year which includes income for my spouse and myself.

 I am submitting documentation of my individual income  (Forms W-2 and 1099)

 I am qualifying using my spouse's income; my spouse is submitting a Form I-864A

Indicate most recent tax year 

Sponsor's individual income $ 

Sponsor and spouse's combined income $ 
(If spouse's income is to be considered, spouse must submit Form I-864A)

Income of other qualifying persons.
(List names; include spouse if applicable. Each person must complete form I-864A)