Affidavit of Support Under Section 213A of the INA usets Form L864 Departinent of Homeland Security ‘ou X50 US. Citizenship and Immigration Services Ei ‘Alivio Support Sabmiter ect 9A Review ‘Number of Support ATidavis Fie 1 Pationer MEETS DOESNOT MEET or 02 Saas regener requrenen 2nd Jit Sponsor aie 1 Sabatite Sponsor one 1 5% Owner Date (nnladiyyy [roe completed yan] EA] Seectihisboxit | Atorney tate Bar Number] Attomey or Ateedted Representative oncreraerates| — foem cater | Gop) {USCIS Online Account Number ian) reproestnre Gt oh L START HERE Type or print nblaek nk Part f. Basis For’ ig Affidavit of Support Mailing Address 2a, InCare OFName ‘he sponsor subi tisaTian aTrappo Basane (Sees ety ane 0s a. Sanne SESE ta, [Lam itepetont. 1 Red oram fling frie Sane ra tomigafon en te re an Bl se O re fe ti. [flea aon wr ptton on eli of he OO [caing tmp ate rntome sy 24. CivoeTow [aarma amare ae. sute[] 26-2 cote 1. C0 Aha onertip me of te spect a = 2g. Province [sawrzaco ‘HER Weanaon wap owTORTTOTOS 24, onal Cote Inending naar, ho irl 9 me 1.4, Ba Lam te ony joint pore te [tam ibe] fest second foi ons Other Information 14 Theoignal etoneris deceased. Lam he Oks cone Tam teeny mga 3 County of Hae oc Nao 4 Dateor Bint mmddyy) [oasiz/2032 Alen Resstaton Number (Aube ve NOTE: Ifyou are ing his form as 2 sponsor, you mu {nce prea of your US. cldzenship, US. nana tats, nwa pemanent reside [PartZ, Taformation About the Principal] 6 USCIS Online Assount Number any) Immigrant iS Ya Family Nate [ssoran aanioza 7. agtine Toepone Number (astm) (Prt Name) SELES, ‘om Sie ot UL REE EM |Part3. Information About the Immigrants You ) |Are Sponsoring 1. Kam sponsoring the pri immigrated i Part 2 BH Yes Ne (Appiabe only fon ate sponsoring ‘amy member in art 3a the second joint sponsor of you are ponsozing family members who we nian ‘oe than sx mom ae the pics inmiaren) 2 Dy Lam sponsoving the flowing faily members immigrating at he same tne ewan sic ments of he pinspl imran named Part. (Do eat Inclae ay elive ited ona septa petiton) 3. D) Lam sponsoring te fllowing family nebo 14a, Family Name (esc Raie) 4b, Gen Nane (stan) 14s. Mile Name 1S, Relionsip a Prispelinmigraat 16 Date of ith (mmddyy) 17 Alien Registration Nuber(A-Narbe) a) 1, USCIS Online Account Number Gan) ‘sc inmigrng orton sions fee nc . Caray Family Members 43, Family Nave 19 family Nome Teal 9b. Given Name 4h. Given Name pi Gstname) sia 44s. Middle Name 6 Duvet Bich (amidai9) 7. Alien Reitraton Number (A-Nunbe (fy) 1% USCIS Online Account Number fan) 9a. Fanily Name (Cas Ra. 14, Mile Name 20, Reaonsip to Pinal migrant 21, Daeof Bich rmideyyy) 22, Alien Registration Number (A-Nunber fay) mA 23, USCIS Online Accoun Number iam) 2, Family Name (ise ame) 9b, Given Name hashes) 2b. Given Name Gaston 9, MidsleName 10, Relanship to Principal migant 11, Date of Binh (isi) 12, Alien Region Namba ANB any) ie 18, USCIS Onine Account Number fan) 2. Middle Name 26 Dae of Binh (mary) 27, Alin Registration Number (A-Nunber fay) ma 28, USCIS Online Account Number an) Form rte Ean 1H AU DRECLEIESREAR ESD PSSRA ESSA REEL Mlari 3. Information About the im ‘Are Sponsoring (continued) 29, Enter the al punber of mig you ae sponsoring oe ‘hisafTidt whieh icles he piel iran sed i Part2 any mgr sein Par 3. Hem Nambers = 28 and Gt appleby rants sted Tortese questions in Par 1. Additonal Information. Do nt cunt th principal inigran if you ae ony sponsoring uly members ning moe tna 6 moths se the pina migra, Part 4, Information About You (Sponsor) ‘Sponsor's Full Name ‘= petkay [rma meee] Graton igrants Vou Sponsor's Physical Address 4 Claw Ose Ore fe. Chor Town 4a, sue] 4a, zinc Af Province | 4 Pos Coe 4h Comey Other Information 5 County of Dorie Ls, Middle Name ‘Sponsor's Mailing Address 2a. InCareOFName ub. Stee Number 6 Dav of Binh (mmvsayyyy) 1. CiyorTowm of Binh Stator Provose of ih 9. Coun of Bint te Baw 0 se O rt fo 2d, CiyoeTown [anos ae, suefe] 20 zipcode [soaeo 2k. Pos Code 2h Coun 3. Is our caren aling alesse same as your pial wis? Bl Yes DN you aneword°No" to Heme Number 3. provide your physical ade ia tem Numbers a= UM DREPSSESREARIRS PIG RSCEA EROS REPRE | 10. US. Social Scoriy Number Reuited) > 22cesess Citizenship or Resiency a. (lam aS. citizen 11. Dam aU. ation 11g. [Tama awl permanent siden, 12, SpomorsA-Number any) 13. Sponsors USCIS Online Ascot Number (a9) Military Service Toe completed by pene ponsor ony.) 1 Lam curenty on eive duty athe US. Amed Forces ers, Cot Guard, ve. baseFor uscis Use Only [Part 5. Sponsor's Household Size NOTE: Do ot count any member of your hosehold more Persons You at sponsoring in this tian: 1. Provide th amber ou nec in Pant, lem Number ». : Persons NOT sponsored in this fant 2. Yous z 3. lfyouarecurentiy mare, ete 1" you ps 44 tfyouhave dependent children, etr th umber as 5. Cie Sine (midsyyyy) 6 DDuremployed Since (mideyyy) 7. Mycuen india saa inom [43,6100 {ncome you are ung fom anyother perton wba wat counted in your household sr, nclaing in cata ‘ondtons,h tnding imigrrt (See Form 6 Testucons) Messe inet name, elation, a nome Person 1 Nene S.ychave anyother dependents ne the number hr 9. Reontip 6 fyowrhave sponsored any ter pasos on Roem £868 oe Form L46462 who ae nw lawl permanent eens 7. OPTIONAL: Ifyou have siblings, pares, ora hen with he same principal esience wo are ‘combining thee income wih our by sbiting Foam [E864 ner te number bere a tS, Hem Nembers = 7. and ener 4% Addroeter umber bere Howshota Sie: [3 Part 6. Sponsor's Employment and Income 1. Ba Employed as an 10, Coren 1 Name 1, Reltonsip 18, Current income s! Person3 1S, Relationship 2. Name of Employer 1 eee: : arora DINER LEASE ARRAN BETO Ioastold Sie at o2 a3 Poverty Gulden uscis Yer: 20 S86 lng as oe} ony [27 8 a9] Povenytive 2 Oe. s Remarks [Part 6. Sponsor's Employment and Income (continued) Eee ‘of Assets to Supplement Income |©ptional) 20, My Current Anna Household Income (Toa al nes fem Par Item Numbers 7 10,13, 16, and 19 he {ota willbe compared to Feral Povery Glin’ on Fora L8GIP) s[a,se.co Di The peoples in tem Numbers 1 Ma a8 1. ave completed Form FS64A. Tam fling song. ith 5 tian al necessary Form -44AS fompleted by these pope 22, Cy One or more ofthe peopl ite in Hem Numbers 11,14, and 17, do not pool to complte Frm [EAG4Abecause he ose the tending iia and has accompanying dependent, Federal Income Tax ture Infrmation 25. Have you leds Federal nome tak et fr ich ofthe three mont recent x yeas? Bava CN NOTE: You MUST tach a photocopy or unset of your Fer income tx teu rely he most een Gi (Options hase anche photcepis or tranerins fy Federal income tax return form send ahd Mey total income autd gross income on lta Revenue ‘Serie (RS) Form 1062) a5 epred on my Pedal nome ‘ax returner thermos resent hee yeas wa 2a. Most Rosen 2023 | [43,961.00 2b, 2nd Mot Recent s| he Sel Most Recent s| 25, Cy Las not requited to les Feder income te een ‘my income was below the IRS equi eel nd eve stached evidence oppo ths your inom, orth ota income for you and your brea from Part 6, em Numbers 20,or24a,- 24. exceeds he Federal Poverty Guidelines fo your hosel ize, YOU ARE. [NOT REQUIRED to compltethis Prt. Spo Part Your Ast (Optional) 1. Enlerth nce of al saving nd checking scouts, s| 2 Enerthe net cath vale of es-sne olin (Net ‘de vans cent steed value ins mrigage db) s| 3. Emerthe net eas vale of al seks, bonds, cers of psi and any aber assets no aed ele n s 4 Addtogeher tem Numbers 1-3: apd eter the amber ere TOTAL: §) ‘Assets rom Form S644, Par 4 Ile Number 3 Sa, Nae of Relive ‘Sb, Your houtcold members ass fom Form 18648 (eotal, Fi Assets ofthe principal sponsored immigrant opin). The principal sponsored immigrant isthe person ised in Par 2m Nombers 1a. Only ined he ect if he incipient being sponsored by ths aia ot suppor {6 Ee te balance of the pispal immigrant savings and checking accom S| 7. Enter tne net ach vl ofall he prineipal migrants realest holdings (Net ale means investment ie Imimsmeraagedet) ‘Enter the cuent cath value ofthe pial inmigrars stocks, bonds, cates of depos an thers not Included in ere Nember 6.0 ext Number s| I REREAD ERE AB Ml‘owsrbod Sie | Poverty Guang ‘Spontors Hovschld Income ] Remarks ufig[2" 22-231 ver 20 SSlos os o6 ae Is ony {27 G8 G9] Povey line 12 oer__| 8, est of a ng mre Ee fr ton [Part 7. Use of Assets to {Optional (continued) 9. Add together tm Numbers 6-8 ond cr he amber tere : upplement Tncome 10, Addtogthr Hem Numbers 4 8, 089. and ae the ber ers ‘Tora: s| [Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certitieation, and NOTE: Read th Penalties scion ofthe Form 864 Tnstutons before omen tip, Sponsor's Contract Plone eh, ving th Fo LB, you ae a ‘sume certain specie obtigton nde the rt ed ‘atonaliy et (INA) and other Fede avs The flowing panera deserve thowe obligation. Pls ed te {eowing infomation erly bore you sgh Form 64, If youd nt undetnd the abligations, you my wish conse an atomey oracredied representative ‘What the Legal Eet of My Signing Form -8642 you sgn Fort 64 onbealfof any person (led the inning immigrant) hoi plying fr an immigrant isso ‘Gradjusnent of stats toa awl penne sient a ht intent migrants Fo 8 tthe US. Goverment with hi or he piste fv an mit ino simon of as, nde INA section 2134, the cs fret contrat Boveen you sd the US. Goveren, Th intending immigrant becoming vl pnanent ett the consideration for he const, ‘Under this contrat, you are tain ding whether tbe Intending immigrant can eal that eo sh nat. inedible the United tts aa pron lily scone & poblc charge, te US. Govemment can consi out noe Sndasset a aval for te supp fhe neing immigrant ‘What 1 Ghose Noto Sign Form 8642 ‘The US. Goverment canot mate you sign Form -864ifyou donot want te doso. But ifyou do net sign Form F464 the icing migrant ay not become awl permanent resdest nthe United Stee. ‘What Does Signlag Form L864 Requte Me To Du? an tending immiratbecomes nul enc eset inthe Ute Stes ted on 3 Form 1-86 tht ou bave Signed then i jour biations under Ferm 864 terminate, A Provide the ited nigra support cesar to msn him or her at as income tate tle 25 pect ofthe Federal Poverty Gadtnes fori or er hoteold sis (100 percent iyo are the pions sponsor and are nave ty inthe US! Armed Forse or US, Cot Guard and the erin i your husband wife, or unmared hd iver Years of geod aly US. Citazaship and lnmigraon Services (USCIS) of any change in your ade wih 30 ays ofthe chang, by ing Form 865 ‘What Other Consequences Are There? an itnding immigrant become fa eave sient ‘ne United Str Sedona Form L464 that you fase ged then um our bligations unde Fae 86 emit, the US. Government may cosier (deem) your income and sits as vailable thal person in deteining wheter be ot ‘he chile for ceran Feral meanest publ beets. nd 10 for ate oll mare pi bel the tate or ea govern’ rls provide for onion (Geeming) of your income and aszt a valle othe pein, ‘This provision dos nat py to public ef specif in sexign Ae) ofthe Welfare Reform Atcha emereey Medica, shore, or-ash emegene rele svies rove unr the Natal Shoo Loch and Child Naelon ‘Retr inmaniations an tenga etnent for ‘ommnicale ies: nd meats porns unde the Elemento and Secondary Eduston Act What 1 Do Not Ful My Obbgains? Ifyou do not provide sient upportothepsson who Becomes ul permanent resident based na Foe 864 ‘ha you signed th person may sue you os spp. URE RRS AE TRE NMS I[Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature (continued) Ifa Feder ste, lol or privat agency provid any covered means-tested pablic beni othe paso ho Bens nw Dermanet rein sed on an -64 tat you sie, the geey may ask youto reimburse thm forthe moun of the benefit they provided. Ifyou do nat make the einem, ‘he agency may se you for he ous tha the ape Bees lf you re sued, nd he court ners amen agit you, the prion ofan hated you may wea eal permite Frocedres fr eforcingo colin the jeden. You my Sho be required fo pay the cos of eal, nluing It you do not le properly completed Form L465 within 30 dag of any change fare, USCIS nay nose acl ine or your aling doo. ‘When Wal Thee Obligations End? ‘Your obligations wer a Form I-86 tht you signed wil edit the petson who becomes awl permanent resent based on tineaeanit AL Becomes aU. ie Has woke or can recive crt for 40 quer of CNolonger ar nw pemnanst eet tts and ha depres he Unie Stas . Issubject removal, but pis for and obtains, in remoral proceedings a nev grant of atment of Stas, based on anew affidavit of pp. ane seu oF iss NOTE: Divorce doer not trmiate your obligations under ‘Your obliations under a Form 86 that you signed loc if youdle. Thee youd, youre ot rete 10 {ake esponsbliy forthe pasos suppor ae our dea, However, yur esate ay owe any spon tht 30 cumulated before you ded, ‘Sponsor's Statement NOTE: Sel the fr the tem Numb Ifappliabe, set heb or Item Number 3 1a [teas read and understand Engi hve read sndundrstand every questo sid instuton on hit idan my answer to ery aueton. 1b. [The interpreter aed in Part 9rd tome vey ‘esto and nsretn on thi iv andy ‘Tanguga wich Tas Tana and Tandon evens, 2B Atmy request he prepe nned in Par 10 ‘repaed i alla rte Tad ay onan {nfomation provided or authorized ‘Sponsor's Contact Information 3. Sponsors Daytime Telephone Number 4 Sponsor's Mote Telephone Number Fan) S. Sponofs Eni Addo Gary) ‘Sponsor's Declaration and Certification pooespieof altered, original documents and understand That USCIS orth U.S Deparment of Sate (DOS) ny eae {he Furthermore, aor the rele ofan inrmation from ny and al of my record tht USCIS or DOS mayne 0 ermine my eligi forthe Bnei ha eck, funhenore autre let of notion cetand in this adv in supporting doamen ad in my USCIS oe DOS ‘econ, iote enties and pesors where necessary forthe ‘inion el enforcement of US. gation la ceri unde penalty of py tha al of einfoematon a ‘my dvi ad any document subited wih were povided (or autora by me hat evewed ad understand al of be infrmatio contained is an submited with my fia and ‘hata of hs ifoeation complete, tue, and core. [AL Low th contents ofthis adit of spots signed: RL have en and J understand each ofthe obligations described ia Par 8 and ase, ety ond witht {cept cach a those obligations in rd to make it poste forthe immigrants nae in Pat 310 ‘Become nfl peranent residents ofthe United Ses, C_Larce suit tothe personal raion of any jireition of weit apie meta ence my ‘isons andr is or 68 EINER age ToC 10[Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature (continued) Interpreter's Mailing Address aL Sime Namber tnd Name ‘Dich ofthe Federal income ax returned in spor of ie afidvit arte soe or re ler a ameristar ied wh he RS, 1 Funderstand hati am elated tthe spensred inmigrant by marae, the termination of be matiage (by divorce, isolation, raaimen or te legal proces) wll at eleve me stny ligtions unde is Farm 86K and Luthor the Soil Sear Aditi to selene infomation abut ai soe USCIS ana DOS, ‘Sponsor's Signature 6b. Daw of Signature middyy99) [osres/2oza NOTETO ALL SPONSORS: Ifyou 6 ot ample ut this oe al sb requred document i a (hetntrcions, USCIS or DOS may dey your ie, [Part 9, Tnterpreter's Contact Information, (Certification, and Signature Prvie the flowing imation about he nero. Interprete's Full Name Inwpete’s Fay Name LastName) 1, letspters Given Name (Fit Name) 2. Inept? Business or Orgaizaton Name iany) LINE RA ee APSR RASS EPS ws OmOs Om 4d aa. sie Ae. 21P Co| 3g. Pos Code en Interpreter's Contact Information 4. Inepeters Daytime Telephone Number S. _Ineqreers Mobile Telephone Number ia) 6 teeters Ena Ades (an) Interpreters Certification ceri unde erly of iy that: an lenin Engl and ich the same language Speaiiod ia Par Kam: Number "band have edo this sponsor inthe Mei angage ‘vey aston and natucton on th ade adsorber “answer to every question. The sponsor nfrmed me that he or ‘he under very testrction,queion and taser he fidav cluding the Sponsor's Delration and ‘Cetieation, andi verified he era fever awe. Interpreter's Signature Ta Inert Signature 7m. Dae of Siar (mmisshy9y)[Part 10. Contact Information, Declaration, and Signature ofthe Person Preparing this AMTidavit, if Other Than the Sponsor. Provide te flowing information abo he preparer Preparer's Full Name fa. Prepare’ Family Name (LastName) 1b, Pepa? Given Name Fit Name) 2 Propree Busines or Organization Name fam) Preparer's Mailing Address 3a. Steet Number [653 wean 65 STREET and ane a6. Dan 0 se. fier aa. site] ae. zr coe [n0055 Sac eueuecechecceaccceiscce: Se Pos Cote 3a. Cou Proparer's Statement 7a, (Blam tan tome or acrid representative bt ve prepared th afi on Bel fe pons 1h, Ham an atone o acrid representative and my epresattin of he sposor inhi cse estes oes nt extend beyond he Peyraton oF his aia. NOTE: Ifyou are anatomey or acres repent, you may be obliged o submit ‘ompleed Porm G28, Nos of Ext of ‘Appearance as Aone o Accredited Representative of 6-281, Notice of Ey of Appearance a Aone in Matrs Oust ‘Gograpieal Cones ofthe Unies Sts, with hi sic Preparer's Certification By my situs, cei nde penal of pry tat Pept his avi at te request ofthe spoon The Sponsor ten reviewed this completed adit nd informed te that be ore understand al th oration contin in and submited wih hs or her affidavit. clang the ‘Spontors Declaration and Certieaton an that al of hie Information complete, and corer. Tcomplete is sMtdvit bce nly orf that he poor povided © Preptrers Signature Preparer's Contact Information S. Prepares Mobile Telephone Number (fy) 4. Prepares Date Teleptone Number fax29275963 foresoe6749 6. Preparers Ema Addr (a) [cssurrsenvrcEecnrt.CoM MUIR ESPLERSRE SSA Foe Ml CEs sn. Dato spe Aayyyy) [6372572026[Pare 11. Aaaiti If you ead ext pace to prove any aditiona ination ‘Sa. Page Number Sb, Pat Number Se. km Number swith aia othe pac bow. Hyounesd more Space than what s provided You may make copies hs age ‘complete and file with hie affdai oath spas sect. ‘of paper Typeor pint your mame ané ANamber an) a he tep ofeach sect inca the Page Number, Pat Nomber, tn tem Number which your answer res and sig and fc ach set Fooly Nine ESpERAL PaREE (es Name) ELENA Le Mile Name [2 2. ANamber (am) mA 3a. PageNumber 3h, Par Nomber Se. Hm Number Ga, Page Number 6b, ParNumber Ge. tem Number a 4a, PageNumber 4b, PutNunber he lem Number 7a, Page Number 7b, Put Number Te, em Number a Footie tin 120821 TIRESo OSC AIDES RRR | ge 196010