Affidavit of Support Under Section 2138 of the INA Users Form L868 Department of Homeand Securit US. Citizenship and migration Serves spor Subneer | Secon 134 Review ‘ember of Suppor ATi Fle ror | 9 Peon © MEETS © DOES NOT MEET a1 a2 et | ciate ‘reemens fumes | ‘ae | © 2nd it Sponsor ae nly | soa Sponsor ie 0 84 0mer Dat omiayy [robe competed by an] LSet thisbox i] Atiorey Stave Bar Number — | AWoraey or Accredited Representiive Tebecompaet yn] Cl fcr | sxe focmttatenaccincane ay representative (ay) C781 auch > START HERE Type o Part 1. Basis For ‘Afi Mailing Address 2a, InCareOfName 1, beexsow n esProne cameea. a he sponsor sobiting eatin aT app {Selec on one bo: i. aes tn BB fam thepetioner 1 fled am fling or he sndName [CALLE tN BREN Immigration of my selie 2 oe se re fs 1b. [] [led an ain work ation on belo the 14 Caton [RS] ae. saue[] 26 rcote eC] ave ooentip ines ofa a5 pen in a fst 2g. Province [vinta conzauee WEG Tiaimaicanne pein ooTaTOR 2m, rusat coe [ouintnae incaig innit win aed 2 [exwrzngo 24 comiy 1, Fa the only jin sponsor, eC) tame D) test 1 second fo eit spoon. Other Information 1. Ey The rg! ptioner ie deceased Lam the subsite sponsor Tam the ncding migrants Coun of Cizeship or National NOTE: Ifyou are ing hiorm as asponsor,youmunt Date Bich mmiddiyyy) [07/23/2007 Incl prot of our US. citensip Saati stat bpm gecietsorpete re S._Alien Rgisation Namber(A-Number any) ma 6 USCIS Ontne Account Number an) a Family Nave (Caste) fesranas. coma 17, ayine Telephone Number 1k Given Name (is Name) Le Midie Name sera UBUIRER FRSAUNHESPREIRREY RE bare1. Tam apoosoring the rinspl nigra named in Pare. Be Yes [No (Appia nly ifyou are posoing family members in Part athe son Join spomar arf you ae pong fi members iho ar imigting snore than si mae afer the iia ‘mira 2 Lamsponsoring se flowing fay members immigrating athe same tine or within mons of ‘he pcp immigrant named in Part 2. (Do ot inte any lative ited on cpr vi pon) 3. Cy Iam somoring the flowing family members who reining more tan si nos arte pina Family Member 1 fe cakes ee amily Member 14a. Family Name (stam) L___ 14, Ginen Name (istName) He. Middle Ne 15, Relinshipo Pipa migrant 16, DateoF Bi immveay999) 17, Alin Regist Number (A-Number) any) mA 1K USCIS Onine Account Number Cifay) Family Member 4 1a. Fanily Name (ta Name) 4m Given Name (Ps Name) (Fre Name) ie MideeNone[__———S—i™Yd 6 Dateof Bit mis) 7. Allen Registration Numb (A-Nomber any) mA USCIS OntneAssoune Numer iany) 9, Family Name Name) 94, Middle Nee ee cnmeliees 22. Alin Region Namba (A-Namben ian) mA 23, USCIS Online Account Number fan) Family Member 5 2a Family Nave (Cathe) 9h, Given Name (same) 24, Given Name (ante) 9. Mile Name 10, Relationship w Praia migra ate of Bit rmiiyyy) Ss 12, Alien Registration Numb (A-Nunbo) ay) mA 13, USCIS Onin Account Namber an) 244, Mile Name 26 Daeof Bink middyyy9) 27. Alien Region Number (A-Numbsr fans) ma 2%, USCIS Online Account Number ian) »[ BU TRESRISREAA ESSER EERIE EB |mm About the Immigrants You | [Are Sponsoring (continued) 29. Ent he total numb fing you ae ponsering on thisariavt which ncodes the piel imma ines any ingranssted nPar Hem [Numbers .=28 a appa a cigs ied fortheseqletons in Part Aiton taermatin Do net count he prepa ingen you are ony sponsoring family members ning moran 6 moths ser the principal imagen [Part 4. Taformation About You (Sponsor) ‘Sponsor's Full Name 1a. Family Name (cathe) 1k. Given Name (istName) ‘Sponsor's Physical Address snd Name 4b Dan O se OO Fe 44%. County Other Information 5 County of Domicile 1. Midile Nome rare Sponsor's Mailing Address 2a, InCare OFName 2b. Sees Number SuestNunber [557 gasp ave Sama? 6 Dateor Binh mild) [087673988 1. Ciyor Town of Binh 8. Site or Province of Binh 9. County Binh de Bam O se O re fo 2a, ciyorToun [anoane ae suey] 2 ziPcode[toaeo 2g. Province —__] i. aoe eee |. lryowr coment naling adds te anew your peal ae Yes [No you never ?No" to Item Number 3 provide your physical adress inte Numbers = 10, U's Social Seer Nomber equied) Cizensip or Residency ha, 1am US. ten, 11 Cy Lam 2 Seaton "he: [1am alow peonaent esden. 12. Sponsors A-Numbe fan) vo 13. Sponsors USCIS Onine Acsoant Numer iany) Miltary Service (To be complete by peter pono ony) norman metre UBDREPSESSEAHIR POCA SROC KONE RE l |For uscis Use Only [Part s. Sponsor's Household Size my member of Your Roush more Persons you are sponsoring in his aidavie: 1. Provide he umber you cated in Part 3, tem Namber 2B [aa] Persons NOT sponsored inthis aia 2 Yours z 3. fyou are carey mate, eter “1” your spe 4. fyou have dependent cide, eter th nko ere S CBRetied Since midyyy) -— eee] 6 Div seiployed sine (midday) Incoane ym ore ning from ay scr person whe was conditions, the intending immigrant. (See Form 864 Inston) Please inate mae, relionsi, a income, Person 1 'S._youhave anyother dependents, enter the nmber ere 9. Relaonsip {6 Myouhave sponsored anyother persons on For 86 oF Form LRGSEZ who ae now evil pemmaent resents 7. OPTIONAL: you have sibs, pres, or al children withthe Same peicia esence wo ae Eembining ter incre with ours by sabmiting For T8648 tert ube bere 7 8. Addtogater Pare, lem Nembers unber here Mouse sie: [2] [Part 6. Sponsor's Employment and Income and ent Enpleyed alae 2. Name of Employer | 3. Naneof Employer? apps) 10. Current Income s| 12, Relationship 15. Relationship 16. Current income s! 1, Name 4 Csetnptoyed ae wan (Occupation) 16 Relsionsip reat Income s| LU DRESSES GOEDEL ASAE Fa |Toc ie] Paes Gane | ema te foro? o3| ws vscis oj gs ge ae ty Jor ot oo | tounine Bote, [Part 6. Sponsor's Employment and Tncome continued) [Part 7. Use of Assets to Supplement Income (Optional) 20, My Current Anpual Howrhold Income (Tl al nes fom Part 6 tem Numbers 7101316, and 195 the taal wl be compared a Feder! Poverty Guilin: on Form F864?) Fi 21, ( Theppl ised in tom Numbers 8 1 Hand 17bve completed Form F688. a lig cows, ih hifi al esesry Por 86448 Complete y these people 22 Cy One or more ofthe people stein Hem Numbers B11, 14, and 17s not ned to complete Form [TRG bedaae he ose fhe ining iat and hs no aecompanying dependents Name Federal Income Tas Return Information 28a, Have you led a Federal income tak ret fr ech of the thos mot een x yea? veo NOTE: You MUST ans poocopy tani of your Fedral income txt forenly te most een, ‘axe 248. (Optional) Ihave ated photocopies or tants ‘fy Federal nome tax returns ory send nd {hie mom reven syut ‘My tol income (adjusted gos income on Internal Revenue Serie (RS) Form 104022) sep on my Peer income taxes forthe most resent years was TaxYeor Total income 2a, Moa Recent 2022_| [30,580.00 2b, dnd Most Rese s| 21g Sed Mos Revert s| 25, [tas not eee to les Fer income tx et my income was ow he IRS equi level a ave ashes evideoe to sppot th your none orthe al income for you nd your boss, ftom Part tem Numbers 30 or 24,246, excl he Federal Poverty Gudelins fo your hosel sie, YOU ARE NOT REQUIRED i conplete ths Part 7. Sip t Part Your Assets Optional 1. Entrthe bale fal sng and checking acount s| 22. Ee the ot cs val of ease lng. (a ‘alc meet curentesexad valve min merase dt) s| A. Ener the net cath vale of al ks, bon, caries of deport an any oer art naaendy cle Hem Number to em Number 2 s| 4 Add opeter Hem Numbers ,~ 3. nd ener te nue bere TOTAL: 5) 1.8646, Par 4 lem Number 3 for SA. Name of Relive (options. si Assets ofthe principal pomsored immigrant (opin). ‘The pina sponsored iin isthe pron iste in Part 2. tlem Numbers - Le, Only alae he abet the icp inngrantisbeing porsored by tis iat of Sip 6 Emer the balance ofthe principal immigrant’ savings and ‘heckng accounts S 7. Ener the net ash vale fal the principles realest holdings. (Net value means investment vale rinsmocgagedeit) gf] 4, Enerthe curentcsh vale ofthe principal migrants socks, ond, etfetes of depr and other ats ot include nem Number 6.0 Hem Namber 7 s| MULDER REPRESSES ALESSponsors Household Income Remarks THowsebold Size] Poverty Gide fer Jot o2 a3 use Your 20 ScS)o4 a5 a6. 5, ony [D7 08 G9 Pomolin | Reea 1D Otker__ cep felnsganc cen of fp ie OS rh [Part 7. Use of Assets to Supplement Income (Optional (continued) 9. ‘Ad ster tm Numbers 6 and et the mbar ere | “ota Value of Assets 10. Addiogetiec tem Numbers 4, 8 and9, dn ent the umber ers ToraL: 5| [Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read he Peale ston fe Form 864 Trsruction bef competing this pt ‘Sponsor's Contract assune crtain specie cbigaton under he rmaration Natlonaliy Act (INA) andthe ede inv. The flowing papaps desert hose oblisnons. Please rend the folowing infomation carefully before you sign Foon I-86, If you dont understand the obitions, you my wen comet Aatoey or seeded representative ‘What the Leg Eset of My Signing Form F-8642 you sign For 1-6 on belo ny person (led the nending immigrant) who i plying fra migrant vis oF {ov agjusimet of sso awl permanent eden, hat lntnding immigrant bts Form 1864 the US (Coteret wth his br api fora migra vs ot jester of sts, under INA seton 213A, the scone treat contact between Jou athe US. Goverment. The intending immigrant becoming nfl peranc reside! is the comideaton forthe conc. Under his contract, you age that ia deciding wheter he intening iigrar ca sali that he or ake rok Imadmisbe othe Unies States a person ily become & public charge th U.S. Goverment can conser our nome fd aes salable othe sport ofthe nding ‘What 11 Choore Not Sign Form 18642 ‘The US. Goverment cana make you sign For 1-864 ifyou donot want 630. But youd ot sigh For 868, he neni imatgyant ma a become a lawl paraners resident nth United Stes, an intending immigrant comes nfl pemanent ident inthe United States bated on orm L884 tat you have Signed en ul your obligations under Foo F864 trie, ect 0 aan io be at coe least 125 prc’ ofthe Federal over Guidlines fori or her houreolé size (100 percent you are ‘he petioning pomorand aon mie dyn he Us! Amed Fore or US, Coast Guard an the persons your husband wf oF banat ila der21 years of ge and Notify US Czeship 2d mization Services (USCIS af change our adres, thin 50 {ays ofthe change, by Hing For Fan ntendingimigrn bscomes ave permanent ident inthe United States bred ona For LAG tayo have Signed then, unl our obligations under Form 864 ent, ‘HEU, Goverment may consider (deen your income and Assets ab valle oth person in determining wheter be ot the lie for ean Fedral ane tested pubic beefs, ‘ad also for ate or local meanest publ beefs ithe ‘Stores goverment les provide for onierton {deesing of your nce and atta valle tthe peso, ‘This provision dos not apply publi beefs pci in section 403 ofthe Welfare Reform Actuch as emergency Media shortsterm on-eash mergeny cle sree ovied uncer te Nana School Lunch and Child Nuton ‘et inmnnisions and teagan west or emunicabl sass and meanest programs under the Elementary atd Secondary Eduetion Act ‘What 11 Do Not Fai My Obtignions? you do nat provide slice suppor tothe pein who comes awl prmancet resident based on Fars 864 ‘he you sige thet pert nyse you Torts upper (I/DREIRKN URL TRSS EESTI RSMPart 8. Sponsor's Contract, Statement, Contact |] {information, Dectaration, Certification, and ‘Signature (continued) a ede sat cal or poate agency provided any covered Incasested pubic benefit the person who become» nfl Pemanat sien based on Far F854 that You sane, he gency ty tk you eimbure tem forthe amount of te nels thy provided. you donot mae the reimbareen, ‘theagency may sue jou forthe south the agency blew I you ae sed, rd he cour enters judge asi you, he emo oragency tat sed yu may as any ely pried ovedures for enforcing o calleting te ademect. Vouray So be required pay the cosa callacton,nling sey foes. you do not lea propery completed Fm 865 win 30 day of ny change fn, USCIS may impose ci Hoe foryour filing 600, ‘When Wil There Obligations End? ‘Your obligtions under Form 864 ht you signed wil end ‘he person wha becomes lawl peonanent reside based 06 afi A. Besomes a US zn 1B. Has worked, orcan eosin xsi fo, 40 quatrs of (C._Nolonger as awful permanent eset tats and has epee Unite Stats 1. Lssbject to removal, bt pis for and obtains, in removal pressings, nem gam of adie of Sat, bed ona new afc of support, oe is NOTE: Divorce dows nt teins yourabligatlons under Fm 864 ‘You obligations under a Form 864 ht you signed alo ca if soudke. Theale, you de, you ete sot reauited to fake esponsibility forthe pens upp aer ou Sah, Fowever, your esate may owe any spor thal 3, scutes before yom ied Sponsor's Statement NOTE: Ses the Box fo ether Hem Number Lor applicable, sl th box fr tem Number 2. 1a, [] teanread and understand Engh and have read tnd understand evry question and insretion om this [ida and my answerto evry question 1b. Theinterpretr media Part 9rd ome every ueton nd enton on ths aft and my ‘TangaageTa wich Tar Moet aT wriood venting 2.) Atmy request th prepare ned in Part 10 ‘peje Gi aid fore Bad oy por Information provide or suthrzd Sponsor's Contact Information 3 Spon’ Dayne Telephone Number Sponsors Mobile Telephone Number any) Sponsors Ena Ades iam) ‘Sponsor's Declaration and Certifiation potocpir of naar, opin Socunta I wndertand Thm USCIS othe US. Deparment of Sate (DOS) may ee Ut sbi origi documento USCIS or DOS 2 er from ny and al fy record tht USCIS or DOS may nse 0 ‘deerme my clip frthe bene tht ack theme auorize lee of norton contained inthis fav supporting documents, and ny USCIS or DOS. ‘econ othe nies and persons where mecesary forthe ‘nistaon an enforcement of US ira ew ceri der ena of sry, that al of he feat in ny affiavit and any sumer scone with kere provid (eautorand by me, at [reviewed ad understand ale the Infra onan an ube with my afd and that of hs ifomatn complete, vue, and east. A. Lio th coats ofthis adit of spt sieed R.Lhave ed and understand each ofthe obligations serbia Par. aI are, ely nd without ny ment eservation or purpose of eran ‘cept each of hose obiations in odern make it pestle for he immigrants insted in Par 31 ‘become lawl peanent resets ofthe United ‘Stes Feder or state court ht ht subst mater. jection of wn aging meta enfece my blipsone under this Form (85 LINEA REPRESSES TAS ERIC[Part 8. Sponsor's Contract, Statement, Contact Information, Declaration, Certification, and mature (continued) Inierpreter's Mailing Address acho the Federal nse takes abd ‘sport of heft arte copies re atered nx tasers of teat ets Hed wh he RS EL onderstnd nam ltd the sponsored inmigrant by marae the termination a he mariage (by ivrce, isolation, anulent te egal proces) wll nt rele me omy histone under his Form I-86 ad 1 Lauthrze the Socil Seay Adminisrasion 12 ‘oleae infomation abot me init sods to USCIS and Dos ‘Sponsor's Signature 6. Spurs Signe ARC 6b, Due of igmue (emily) (osras720ze NOTE TO ALL SPONSORS: yu do ot completly i ‘ut tis ait of alto subi egeied documents ited in the Inco USCIS o¢ DOS may deny your ai, [Part 9. Interpreters Cont (Certification, and Signatu etTnformation, Provide the folowing information aout he ier Inierprete's Full Name Aa leet Fanily Name (Last Nae) a) 15 ape cet 2a? Busines or Organization Name Gay) ELDERS SERRA SER 30. Am C1 se Fe Se Giy or Tom ‘34, ZIP Coie aa. sal Mt Province Sig. Postal Code Sh. Coun Interpreter's Contact Information 4. Ineteters Dayne Telephone Nur Innes Mobile Telephone Number) 6 frp Ell Addo any) Interpreter's Certification eri under eal f ey tha 1am fen Enlish and Tan have reat tis sponsor the ete ange ‘very gusto and instrcton on thi aft nde nse fo every question. The porsor inked me hate or ‘he unerans vey nrtton,qoeon and answer onthe icv ining the Sponsors Declaration and ‘Creation, an as verified he esa of eer anew. Interpreter's Signature “a. Inept Signe Th. Dato Signature may»)Signature ofthe Person Preparing this Affidavit, if Other Than the Sponsor Provide the following intormaton boat ie prepare Proparer's Full Name 1. Pepar/+ Family Name Lat Name} ‘Ub, Prapazers Givea Name (Fit Name) 2 ee mau joes or Orpnization Name Fan) Preparer's Mailing Address 3b C7 Ane 1 ste 6) re. fier he. Ciiyor Town few vou ad, Sate [iy] 34, Z1Pcoae[t0033 (an Sg. Postal Code 3 Coaney Preparer's Contact Information a Daytne Telephone Number ‘5. Prepares Mobile Telephone Number (am) 6 Pspres Ema Aires tam [GSSNOLTISERVICEEGYAIL, Com Preparer's Statement ‘ta, (Lam nt an atomeyo accredited reeset bat have prepared this afi on Bbal ofthe sponsor and with he sponsors consent, ‘a. Lam anatorey or ascredied epresentative and my representation fhe poner in is ae Clevtends (doesnot eend beyon the Preparation ofthis aan NOTE: ifyouare an atmey a ccteted representa, you may be obliged submits Completed Foon 0:28, Notice of Eaty of Representative, o 28, Nowe of Ey of Appearance attorney fn Mates Ouse the Geographical Conines ofthe United Sates, wih he Proparer's Certification By my senate I cei, under penal of pry tha repre hs adit at th rogues ofthe pono Te pons ten reviewed ths compltd afd nd inc Ine tht he or she understand al ofthe information contin Ina abmited wah hs oer affine the Spomr's Declaration and Certain, nha all of this information is complet, tue-andconget. complete his Mfidavit tased ony on formation) the sponse provid to Ine orathorzesmt aba ote PreparG's Signature fa 8b. Dato Sennyd mmitasasa) — [o3/a8/202% ‘stan ene tu BRR RSENS Peetyo need exva spate provide any aio ivomnaton| vidi his ian ue the space bow you need more Space tha wha provide, you may make coisa his page ‘eo complte and ile wih this affair mach spre set ot pane Type or prin your mame and Amber (any at topo each sheet ict the Page Number, Par Numb, ‘nem Number a which your anewe fr and igh and a Fanily Name (ar kame) Given Name (ts Name) Le Middle Name fara ———S—~*Y 2. AeNumber (any) ‘Sa, PageNumber Sb. ParNumber Se. Hem Number 3a. PugeNumber Ab. Pa Number 3 Mem Number 6a, Page Number 6, PantNomber Gem Nunbee 4a. Page Number 4b. PanNunber 4s, Mum Number Ta, PageNumber 7b, PartNumber 74, lem Number 4a ERR PRAMS ACP |