Affidavit of Support Under Section 213A of the INA USCIS Form 1-864 Department of Homeland Security OMB No, 1615-0075 US. Citizenship and Immigration Services Expires 12/31/2023 [. “Affidavit of Support Submitter Section 213A Review ‘Number of Support Affidavits in File For | i Petitioner MEETS © DOESNOT MEET o1 o2 USCIS | @ Ist Joint Sponsor fequirements requirements Remarks Use | © 2nd Joint Sponsor Reviewed By: Only | 1 Substitute Sponsor Office: © S%Owner Date (mavdd/yyyy) Geist posit” | Aton Sas BarNanber | Aten or ccdiedRawemtatve rane ay] Yom Gazer | ape USCIS Stine aceon Neer 9) representative (if any). . > START HERE - Type or print in black ink. [Part 1. Basis For Filing Affidavit of Support Mailing Address USES Cote ota) 1 Wamer-LEe Bew oe Jn Care Of Name - am the sponsor submiting hs afd of support becuse phe \ATE- Seow ‘Select only one box): ah sieabeoter La. A Lam the petitioner. [ied oram fling forthe and Name RBoue. & immigration of my relative. ae Op O se O Pe 1b. 1 filed an alien worker petition on behalf of the 5 intending immigrant, who is related to me as my 2d. City orTown [OLD WARBosR. de State[ [=] 24 ZIP Code| Le. C1] [have an ownership interest of atleast 5 percent in 2g. Province which fled analien worker peilion onbehalfofthe 2.4. Postal Code —___iending immigan, who related to meas my 24 Conny 14. [1 tam the only joint sponsor. DAMA te D) Samie 1) first [) secondoftwojoin sponsors. Other Information Lf. (] Theoriginal petitioner is deceased. Tam the sti . Oo ibs posor Tan teincntingimmgrnts 3 Cory of Chizenship or Nanay IAMAICA NOTE: you are filing this form as a sponsor, you must 4. Date of Birth (mnvdyyyy) osf2t/4e4 include proof of your U.S. citizenship, US. national statu, snes (a Shuniet pera hialethaederieeprra 5. Alion Registration Number (A-Number) (if any) >a loGC 5050415 [Part 2. Information About the Principal 6, USCIS Online Account Number (if any) Immigrant » 1a. Family Name 7, Daytime Telephone Nuntber on\N Geena [Ste 67 F-2025 w gesters CALA — Le. Middle Name [ OQuLCeTA Fom S54 Bien 20824 MINER ANISH LL Page Lot 10Part 3. Information About the Immigrants You [Are Sponsoring 4, Lam sponsoring the principal immigrant named in Part 2 [B¥es 1 No (Applicable only if you are sponsoring family members in Part 3. as the socond joint sponsoror if you are sponsoring family members who ar immigrating more than six months arth principal immigran) 2D Tam sponsoring the following family members immigrating atthe same time of within six months of Family Member 3 14.a, Family Name (Last Name) 14, Given Name rst Name) IM.c. Middle Name 15. Relationship to Principal immigrant 16, Date of Binth (mmiddtyyyy) Co) 17, Alien Registration Number (A-Number) (if any) {de principal immigrant named in Part 2. (Do not include any eative listed on a separate visa petition ) -~ 3. CJ Lamsponsoring the following family members who USCIS Online Account Number (if any) are immigrating more than six months afer the principal > ‘immigrant. Family Member 1 Sesily Montes . 19.0, Family Name 4a Family Name (ast Name) (Last Name) 4.b. Given Name 10 Name) First Name) fe Middle Name 19.6, Middle Name s [some hecetiie 6 Date of Binh (mmiddyyyy) 7. Alien Registration Number (A-Number) (ifany) 20, Relationship to Principal Immigrant 21. Date of Binth (mmddiyyyy) 22, Alien Registration Number (A-Number) Gif any) mA >A 1 t 8 USCIS Online Account Number (i any) 24 UBCIS Onli Account Nunta) » Fumily Member 2 Family Member S 24.a, Family Name mas Nan (casthame) 9b, Given News 24,b, Given Name (First Name) os Name) 9c. Middle Name 24.c. Middle Name 410. Relationship to Principal Imunigrant 11, Date of Birth (mddlyyyy) 12, Alien Registration Number (A-Number) (if mA 13, USCIS Online Account Number (if any) 25, Relationship to Principal Immigrant 26, Date of Birth (mm/ddtyyyy) 27, Alien Registration Number (A-Number) (if any) mA 28. USCIS Online Account Number (if any) » > Form I-R64 Edition 120821 PARRA OG ESCA CYSTS AO LERREGA PNA EI Page 20f 10[Part 3. Information About the Immigrants You Are Sponsoring (continued) 29, Enter the total nimber of immigrants you are sponsoring on this affidavit which includes the principal immigrant listed in Part 2. any immigrants listed in Part 3., Item ‘Numbers 1. 28, and (ifpplicable), any immigrants listed for these questions in Part 11, Additional Information Do not count the principal immigrant you are only sponsoring family members entering more than 6 months afer the prinepal immigrant 1 Part 4. Information About You (Sponsor) Sponsor's Full Name * ge Ba 1h Geert [DAME \-LEE Sponsor's Physical Address 4a. Seeasunter (———_] and Name, 4. ap. O se. O rir Cd 4a. sute[ EJ 4e zr code 4. City or Town 46 Province ig. Postal Code 4b. Country Other Information 5. County of Domicile Uurteo STATES of Americal 1a. Middle Name [Ba sA@ni a Sponsor's Mailing Address 2a. InCare OfName MEI-LEE Bele 2b. Surat Number [TG=Guy ay Green| one ze Can Ose. O rte Caneaa Reigyt re sate AYE] 26 zie code [YT 2.4. City or Town 2g. Province Lh. Postal Code 2k Couy WUwrien Steve: 3. Isyour current mailing address the same as your physical address? Ves No Ifyou answered "No" to Hem Number 3., provide your pliysical addres in tem Numbers 4. -4.b, «& DavotBin mmddyy — [OA¥991 ] 1. Ciy or Townof Bh ST ANORew Sie orProvine of Binh 9. Cousuy of Binh AMA CA 10. U.S. Social Security Number (Required) >[449 31 6OUG Citizenship or Residency ta, [/famavsciizen, 1b.) Lama U.S. national. 11. [J Jama lawful permanent resident. 12. Sponsors A-Number (if any) »4 065050415) 13. Sponsor's USCIS Online Account Number (if any) *Oels 2466 Military Service (To be compicted by petitioner sponsors only.) 14, Lam currently on active duty in the US. Armed Forces or US. Coast Guard. Oves (Ns Form 1-864 Edition 1200821 MILE SSRIS SNE SPA Page 3 of 10For USCIS Use Only [Part 5. Sponsor's Household Size NOTE: Do not count any member of your household more than once. Persons you are sponsoring in this affidavit: 1. Provide the number you entered in Part 3., Item Number 29, = Persons NOT sponsored in this afi 2 Yourself. 3 3. Ifyou are curently married, enter"I* for your spouse. 4. Ifyou have dependent children, enter the number here. 8, [Retired Since (mmiddyyyy) (wie 6. Unemployed Since (mmddyy) 7. My current individual annual income s Income you are using from any other person who was counted in your household size, including, in certain conditions, ihe intending immigrant. (See Form 1-864 Instructions) Please indicate name, relationship, and income. S. Ifyou have any other dependents, enter the number bere. Peron . y i (Sten enThowas . Relaonsip o [S@ouse 6. Ifyou have sponsored any other persons on Form I-864 or ‘Fomn J-864EZ. who are now lawful permanent residents, 10, Current Income $|33,358 CO enter the mumber ere. OQ] Peron? ‘you have siblings, parents, or adult a. Name children with the same principal residence who ae combining their income with yours by submitting Form. a 8644, emer the number hee. 0 Te Relioastip 8. Add together Part Item Numbers 1,7. and enter the ‘number bere. 13, Current Income 3 Housthold Size: [~ a Person 1M, Name [Part 6. Sponsor's Employment and Income Tam currsntly: 15, Relationship 2 1. Employed as alan - Nr Rece' 16. Current Income $s 2. Nameof Employer! Noatyw elt Healt Person ¢ 3. Name of Employer 2 (if applicable 17, Name 4. [Self-Employed as a/an (Occupation) 18. Relationship (vir 19. Curreat Income s Form I-864 Edition 120821 ULTERRSS EA RC REDANEOSEAS BAKE Page 4of 10Houschold Size | Poverty Guideline | Remarks For fo. o2 03 Year, 20 vscis O45 os o6| se , Only [27 D8 G9] Poveny Line: © Otber__ [Part 6. Sponsor's Employment and Income (continued) [Part 7. Use of Assets to Supplement Income (Optional) 20, My Current Annual Household Income (Tota all fromPart 6, lem Numbers 7,10, 13, 16.,and 19,; the {otal will be compared to Federal Poverty Guidelines on Form I-864P.) s[184,4¢3: 00 21, J The people liste in rom Numbers &, ff, 14, and 17, have completed Form 8644. 1am fling along with his affidavit all necessary Form 1864S completed by these people. 22, 1 Oncor more ofthe pope listed in Hem Numbers 8. 11,14, and 17, do not need to complete Form I-364A because he or she isthe intending immigrant and has no accompanying dependents. Name Federal Income Tax Return Information 23.a, Have you filed a Federal income tax retunyfor each of the LUnce most recent tax years? Yes C]No NOTE: You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year. 23.5.) COptional) I have attached photocopies or transcripts of my Federal income tax retums for my second and third most recent tax years. ‘My total income (adjusted gross income on Internal Revenue Service (IRS) Form 1040EZ) as reported on my Federal income tax retums for the most recent three years was: Tex Year Total Income 2a. Mos Recem a2] s[ey,02500 24.b, 2nd Most Recent 21 | § Suucyo 2c. 3rd Most Recent [090 | S| LU,463°00 25, Iwas not required to file a Federal income tax return as my income was below the IRS required level and T have attached evidence to suppor this. I your income, orth total income for you and your household, from Part ,, Item Numbers 20, 0 4.a,~ 24¢., exceeds the Federal Poverty Guidelines for your houschold size, YOU ARE, NOT REQUIRED to complete this Part 7. Skip to Part 8. Your Assets (Optional) 1. Enter the balance of all savings and checking accounts. s 2 Enter the net cash value of real-estate holdings. (Net value means current assessed value minus mortgage debt) s 3. Enter the net cash value ofall stocks, bonds, centificates of deposit, and any other assets not already included in Item Number 1, or Item Number 2. s 4. Add together Item Numbers 1.~ 3. and enter the number here, TOTAL: $ Assets from Form I-864A, Part 4,, Item Number 3.d,, for: ‘S.a, Name of Relative ‘Sb. Your houschold members assets from Form 1-864 (optional. s Assets of the principal sponsored immigrant (optional). ‘The principal sponsored immigrant isthe person listed in Part 2,, tem Numbers 1.a, ~1.¢. Only include the assets ifthe ‘principal immigrant is being sponsored by this affidavit of support, 6. Enter the balance of the principal immigrants savings and ‘checking accounts. $ 7. Enfer the net cash value ofall the principal immigrants, eal estate holdings. (Net value means investment value ‘minus mortgage debt.) s 8. Ener the current cash value of the principal immigrants stocks, bonds, certificates of deposit, and other assets not included in item Number 6, or Item Number 7. s Form -864 Edition 1208/21 MUIENERANLORES PRESSION SEN Se Poge Sof 10Tousehold Sie] Poverty Guidlie | Spomor’s HowshaldTacome | Remarks For loi a2 a3 adie Year 20 wis |o4 os a6 s Ony |97 08 29] PovenyLive: | meme fat ann meneame (wet moan ent eend? 0 Otter. s. oer padts andthe iene Rare cme ia 1, Aree ren he [Part 7. Use of Assets to Supplement Income |(Optional) (continued) 9 Add together Item Numbers 6-8, and enter the number here. sL_wia ‘Total Value of Assets 10. Add together Item Numbers 4,, §.b,, and 9. and enter the are roma 60] [Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form [-864 Instructions before completing this part. Sponsor's Contract Please note that, by signing this Form I-864, you agree to assume certain specific obligations under the Immigration and ‘Nationality Act (INA) and other Federal laws. The following ‘paragraphs describe those obligations. Please read the following information carcfully before you sign Form 1-864. If you do not understand the obligations, you may wish to consult an attomey or accredited representative. ‘What is the Legal Effect of My Signing Form I-8642 Fyou sign Form 1-864 on behalf of any person (called the intending immigrant) who is applying for an immigrant visa or for adjustment of status toa lawful permanent resident, and that {intending immigrant submits Form 1-864 to the U.S. Government with his or her application for an immigrant visa or adjustment of status, under INA section 213A, these actions create a contract between you and the U.S. Government. The intending immigrant becoming a lawful permanent resident is the consideration for the contract. Under this contract, you agree that, in deciding whether the intending immigrant can establish that he or she is not {inadmissible to the United States as a person likely to become a public charge, the U.S. Government can consider your income and assets as available forthe support of the intending immigrant. ‘What If] Choose Not to Sign Form 1.8642 ‘The U.S. Government cannot make you sign Form 1-864 ifyou do not want to do so. But if you do not sign Form 1-864, the intending immigrant may not become a lawful permanent resident in the United States. ‘What Does Signing Form I-864 Require Me To Do? {an intending immigrant becomes a lawful permanent resident in the United States based on a Form I-864 that you have signed, then, until your obligations under Form I-864 terminate, you must: A ‘necessary to maintain him or her a an income that is at least 125 percent of the Federal Poverty Guidelines for his or her houschold size (100 percent if you are the petitioning sponsor and are on active duty in the US. Armed Forces or U.S. Coast Guard, and the person is your husband, wife, or unmarried child under 21 years of age); and 1B, _ Notify U.S. Citizenship and Immigration Services (USCIS) of any change in your address, within 30 days of the change, by filing Form 1-865, ‘What Other Consequences Are There? {fan intending immigrant becomes a lawful permanent resident in the United States based on a Form I-864 that you have signed, then, until your obligations under Form I-864 terminate, the U.S. Government may consider (deem) your income and assets as available to that person, in determining whether he or she is eligible for certain Federal means-tested public benefits and also for stale of local means-tested public benefits ifthe state oF local governments rules provide for consideration (deeming) of your income and assets as available to the person. “This provision does not apply to public benefits specified in section 403(¢) of the Welfare Reform Act such as emergency Medicaid, short-term, non-cash emergency relief; services provided under the National School Lunch and Child Nutrition Acts; immunizations and testing and treatment for communicable diseases; and means-tested programs under the Elementary and Secondary Education Act. ‘What If I Do Not Fulfill My Obligations? If you do not provide suficient support tothe person who becomes a lawful permanent resident based on a Form I-64 that you signed, that person may sue you fortis suppon Form [864 Edition 1208/21 NTE RETR AVERERETESIAS PR PRDORISE RSNAAR Ml Page 6 of 10Part & Sponsor's Contract, Statement, Contact information, Declaration, Certification, and Signature (continued) Ifa Federal, sate local, or private agency provided any covered ‘means-tested public benefit to the person who becomes a lawful permanent resident based on a Form I-864 that you signed, the agency may ask you to reimburse thom forthe amount of the benefits they provided. Ifyou do nat make the reimbursement, ‘the agency may sue you forthe amount that the agency believes you owe. Ifyou are sued. and the court enters a judgment against you, the person or agency that suod you may uso any legally permitted procedures for enforcing or collecting the judgment. You may also be required to pay the coss of collection, including anomey foes. If you do not file a property completed Form 1-865 within 30 days of any change of address, USCIS may impose a civil fine for your failing o do so. ‘When Will These Obligations End? ‘Your obligations under a Form 1-864 that you signed will end if the person who becomes a lawful permanent resident based on that affidav A. Becomes a U.S. citizen; B. Has worked, or cam receive credit for, 40 quarters of ‘coverage under the Social Security Act; C. No Jonger has lawful permanent resident status and hhas departed the United States; D. Is subject to removal, but applies for and obtains, in removal proceedings, a new grant of adjustment of status, based ona new affidavit of support, if one is required; oF E. Dies. NOTE: Divorce does not terminate your obligations under Form 1-864, ‘Your obligations under a Form 1-864 that you signed also end if you die. Therefor, if you die, your estate isnot required to ‘ake responsibility for the person's support after your death. However, your estate may owe any support that you ‘accumulated before you died. Sponsor's Statement NOTE: Select the box for either Item Number 1.2, oF .b. If applicabje, select the box for Item Number 2, ‘ean read and understand English, and I have read and understand every question and instruction on this affidavit and my answer to every question. La 1.b, [2] The interpreter named in Part 9. read to me every {question and instruction on this affidavit and my answer to every question in ‘a language in which T am fluent, and T understood everything. 2, Fy Atny request, the preparer named in Part 1 prepared this affidavit for me based only upon {infomation provided or autharized. Sponsor's Contact Information 3. Sponsor's Daytime Telephone Nunber Sponsor's Mobile Telephone Number (if any) 5. Sponsor's Email Address (any) SEAN Tomes 2 anim: con, Sponsor's Declaration and Certification Copies of any documents I have submitted ae exact photocopies of unaltered, original documents, and I understand, that USCIS or the U.S. Department of State (DOS) may require ‘tha [submit original documents to USCIS or DOS at a ater date. Furthermore, I authorize the release of any information from any and all of my records that USCIS or DOS may need to determine my eligibility for the benefit that I seek. | furthermore authorize release of information contained in this affidavit, in supporting documents, and in my USCIS or DOS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. ‘oemify, under penalty of perjury, that all of the information in ‘my affidavit and any document submitted with it were provided ‘or authorized by me, tat reviewed and waderstand all ofthe information contained in, and submitted with, my affidavit and Out all ofthis information is complete trie and correct. ‘A. know the contents ofthis affidavit of support that I signed; B. Ihave read and I understand each ofthe obligations described in Part 8., and L agree, freely and without any mental reservation or purpose of evasion, to accept each of those obligations in order to make it possible for the immigrants indicated in Part 3. to become lawful permanent residents ofthe United States; CC. Lagree to submit tothe personal jurisdiction of any Federal or stale cour that has subject matter jurisdiction of a lawsuit against me to enforee my obligations under this Form I-86; Form 1-864 Edition 120821 MULTE PES BPA ORF I Page 7 of 10[Part 8. Sponsor's Contract, Statement, Contact information, Declaration, Certification, and [Signature (continued) D. Each of the Federal income tax returns submitted in ‘support of this afidavit are truc copies, oF are ‘unaltered tax transcripss, ofthe tax returns I filed. with the IRS; E, —Tunderstand that, i am related to the sponsored immigrant by marriage, the termination of the marriage Qby divoree. dissolution, annulment, or ther legal process) will not relieve me of my obligations under this Form 1-864; and F. authorize the Social Security Administration to release information about me in its records (0 USCIS and DOS. Sponsor's Signature 6.4. Sponsor's SES C 6b, Date of Signatare (emmédd/yyy3) NOTE TO ALL SPONSORS: Ifyou do not completely fil ‘out this affidavit or fail to submit required documents listed in the Instructions, USCIS or DOS may deny your affidavit, [Part 9. Interpreter's Contact Informa \Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1a. Inerpreter's Family Name (Last Name) nia Lb. Interpreters Given Name (First Name) Mh 2. Inlerpreter's Business or Organization Name (if any) NIA Interpreter's Mailing Address 3a. Steet Number and Name NIA 3b. Ap. © se. O Fk. Nia 3. City or Town 3a. suwe[ Ee] 3< zi code[ VA 34. Province Nia 34g, Postal Code NIA 3h. Country . fi Interpreter's Contact Information 4. Interpreter’s Daytime Telephone Number ‘5S. Interpreter’s Mobile Telephone Number (if any) NIA 6. Interpreters Email Address (if any) nA Interpreter's Certification ‘Toettfy, under penalty of perjury, that: am fluent in English and { N/A |, hich isthe same language specified in Part, Kem Number 1.b, and Ihave read to this sponsor in the identified language every question and instruction on this affidavit and his or het answer to every question. The sponsor informed me tha he or she understands every instruction, question, and answer on the affidavit, including the Sponsor's Declaration and Certification, and has verified the accuney of every answer. Interpreter's Signature 7a, Interpreter’ Signature 1. Date of Signature (mnvddyyyy) NIA Form -Hét Edition 120821, ABEL Ee PPM Page 8 of 10[Part 10, Contact Information, Declaration, and Signature of the Person Preparing this AfTidavi lif Other Than the Sponsor Provide the following information about the preparer. Preparer's Full Name 1a. Preparcr’s Family Name (Last Name) 1b, Proparer’s Given Name (Fist Name) Nia 2 Prepsrers Business or Organization Name (if amy) NIA Preparer's Mailing Address 3a. Street Number and Name IIe 3b, O An O se. O mr. 3. Cty or Town NIA nia NA 34. State EI s< zceie 34. Province 3.n, Postal Code A Bh. Country WA Preparer's Statement iO] tam pot an attorney or accredited representative but have prepared this affidavit on behalf of the sponsor and with the sponsor’ consent. 7h, [) Lam an atiomey or accredited representative and my representation ofthe sponsor inthis case Clextends [] does not extend beyond the reparation ofthis affidavit. NOTE: Ifyou are an attomey or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Enty of Appearance as Attorney or Accredited Representative, or G-281, Notice of Entry of Appearance as Attorney ta Matters Outside the Geographical Confines of the United States, with this alfidavit, Preparer's Certification By my signature, I cenify, under penalty of perjury, that 1 prepared this affidavit at the request of the sponsor. ‘The sponsor then reviewed this completed affidavit and informed ‘me that be or she understands al ofthe information contained in, and submitted with, his or her affidavit, including the Sponsor's Declaration and Certification, and that all of this information is complete, tru, and correct. I completed this affidavit based only on information that the sponsor provided to ime or authorized me to obtain or use. Preparer's Signature 8.2. Preparers Signature Preparer's Contact Information 4. Preparers Daytime Telephone Number ler Prepurer's Mobile Telephone Number (if any) Nip 6. Preparer’s Email Address White NJ NA Ab, Date of Signamure (mmddyy) — [MITA Form 1-864 Edition 120821 MIDE ARBRE IMSLNERRERESTSP REN OMLRTA I Il Page 9 of 10Part 11. Additional Information If you need extra sperce to provide nny additional information within this affidavit use the space below If you need more space than what is provided, you may make copies of this page to complete and file with this affidavit or attach a separate shoct of paper. Type or print your name and A-Numbcr (if any) at the top of each shect; indicate the Page Number, Part Number, and Item Number to which your answer refers, and sign and date cach sheet 1a. Family Name (Last Name) * Faken) Ld (First Name) 2 A-Number (if any) 3.a Pape Number 3.b. Pant Number 3.c. Itcm Number CJ} LC 4a [ Number 4.b, Pan Number 4.c. Item Number 4d. Sa, | Sib. PanNumber 5.c. Item Number Sd. 6.a. Page Number 6.b, PartNumber 6.¢c. Item Number 6.d. Tw [| 7.b. PartNumber 7.c. Item Number 2d. Form 1-864 Edition 1208/21 MERE RRR AERP RS Page taf 10