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OMB No 1615 0075 .pdf


Original filename: OMB_No_1615-0075.pdf

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10/10/2013
10/10/2013
10/10/2014
10/31/2012
10/10/2013
10/10/2016
OMB No. 1615-0075; Expires:10/10/2013
10/31/2011

I-864W, Intending Immigrant's
Affidavit of Support Exemption
(AOS)

Department of Homeland Security

U.S. Citizenship and Immigration Services

Part 1. Information about the intending immigrant. (You or your adopted
child.)
AOS
AOSFiling
Filing
Filing
Fee:
Fee:$290
$440
$340
$440
AOS
Fee:
Last Name

1. Name

For Government
Use Only

First Name
2. Address

Middle Name

Street Number and Name (include apartment number)
City

State or Province

Country

Zip/Postal Code

3. Date of Birth

(mm/dd/yyyy)

4. Country of Birth
(city/country)
5. Telephone Number

(Include area code or country and city codes)

FEE:
$290
AOS
fee:
$290
AOS
AOS
Fee:
Fee:
$290
AOS
Fee:
$290
This
I-864W:
AOS
AOS
Fee:
$460
$760
$410
AOS
AOS
Fee:
Fee:
$420
$410
AOS
Fee:
$420

does not meet the
requirements of
exemption.

meets the
requirements of
exemption.

Reviewer

6. Social Security
Number (if any)
7. Alien Registration
Number (if any)

Location

Date (mm/dd/yyyy)

Part 2. Reason for exemption.
I am EXEMPT from filing a Form I-864 Affidavit of Support because:
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, 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.
I am filing for an immigrant visa or adjustment of status as a self-petitioning widow(er)
using Form I-360.
under
under
the
the
Diversity
Diversity
Visa
Visa
Program
Program.
.
amfiling
filingfor
for
an
immigrant
visa
or the
adjustment
of
status
as
a battered
spouse or child using
am
filing
for
an
immigrant
visa
under
under
the
Diversity
diversity
Visa
visa
Program
Program.
prgram.
filing
for
an
immigrant
visa
under
thethe
the
Diversity
Diversity
visa
Visa
program.
Program.
an
immigrant
visa
under
the
diversity
visa
program.
IIIIIam
am
filing
an
immigrant
visa
under
diversity
visa
program.
Form I-360.

Part 3. Concluding provision.
I,
of perjury under the laws of the United States that:

, certify under penalty

(a) I know the contents of this exemption request which I signed;
(b) All the statements in this exemption request are true and correct; and
(c) I authorize the Social Security Administration to release information about me in its
records to the Department of State and U.S. Citizenship and Immigration Services.
(Signature of intending immigrant, or of U.S. citizen parent
if intending immigrant is less than 14 years old)

FORMI-864WREV10-08-10Y
NOTE:
MUST with
be submitted
with$420
the AOS fee: $420
Form This
must form
be submitted
the AOS fee:

(Date--mm/dd/yyyy)
Form I-864W (Rev. 10/08/10)Y


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