Department of Homeland Security

U.S. Citizenship and Immigration Services

I-864, Affidavit of Support Under Section 213A of the Act

,
For Government Use Only

OMB No. 1615-0075; Expires 10/31/2011

Part 1. Basis for filing Affidavit of Support.

1. I, LOC BA PHAN am the sponsor submitting this affidavit of support because (Check only one box): a. b. c. d. e. f.
I am the petitioner. I filed or am filing for the immigration of my relative. I filed an alien worker petition on behalf of the intending immigrant, who is related to me as my I have an ownership interest of at least 5 percent in , which filed an alien worker petition on behalf of the intending immigrant, who is related to me as my I am the only joint sponsor. I am the first second of two joint sponsors. (Check appropriate box.) The original petitioner is deceased. I am the substitute sponsor. I am the intending immigrant's

This I-864 is from:

the Petitioner a Joint Sponsor # ______________ the Substitute Sponsor 5% Owner

This I-864:

does not meet the requirements of section 213A. meets the requirements of section 213A.
Reviewer Location Date (mm/dd/yyyy)

Part 2. Information on the principal immigrant.

2. Last Name First Name
NAM PHAN

Middle Name
BA

3. Mailing Address Street Number and Name (Include Apartment Number) City
AP 2, XA HOA PHU, HUYEN CU CHI

State/Province
N/A

Zip/Postal Code Country 5. Date of Birth (mm/dd/yyyy)

N/A VIETNAM

4. Country of Citizenship
VIETNAM

HO CHI MINH

6. Alien Registration Number (if any) A- N/A

7. U.S. Social Security Number (if any)

04/09/1975

Number of Affidavits of Support in file: 1 2

Part 3. Information on the immigrant(s) you are sponsoring.

8. 9. I am sponsoring the principal immigrant named in Part 2 above. Yes No (Applicable only in cases with two joint sponsors) I am sponsoring the following family members immigrating at the same time or within six months of the principal immigrant named in Part 2 above. Do not include any relative listed on a separate visa petition.
Name
a. TO,LOAN THI b. PHAN, THONG BA c. d. e.

Relationship to Sponsored Immigrant

WIFE SON DAUGHTER

Date of Birth
(mm/dd/yyyy)

A-Number (if any)

U.S.Social Security Number (if any)

04/19/1975 10/14/2001 11/09/2007

PHAN, HOANG YEN

10. Enter the total number of immigrants you are sponsoring on this form from Part 3, Items 8 and 9.

Form I-864 (Rev. 10/08/10)Y

Part 4. Information on the Sponsor.

11. Name
Last Name First Name

PHAN LOC

For Government Use Only Middle Name

12. Mailing Address

Street Number and Name (Include Apartment Number)

BA

3904 W. BOSTON STREET

City

State or Province

Country

BROKEN ARROW USA

Zip/Postal Code

OKLAHOMA 74012

13. Place of Residence Street Number and Name (Include Apartment Number)
(if different from mailing address)

SAME
City

State or Province

Country

Zip/Postal Code

14. Telephone Number (Include Area Code or Country and City Codes) 15. Country of Domicile 16. Date of Birth (mm/dd/yyyy) 17. Place of Birth (City) 18. U.S. Social Security Number (Required) 19. Citizenship/Residency I am a U.S. citizen. I am a U.S. national (for joint sponsors only). I am a lawful permanent resident. My alien registration number is AIf you checked box (b), (c), (d), (e) or (f) in line 1 on Page 1, you must include proof of your citizen, national, or permanent resident status. 20. Military Service (To be completed by petitioner sponsors only.) I am currently on active duty in the U.S. armed services. Yes No
484-17-9374
PHU CUONG
07/02/1971

918-978-0485 USA

State or Province
BING DUONG

Country
VIETNAM

Form I-864 (Rev. 10/08/10)Y Page 2

Part 5. Sponsor's household size.

21. Your Household Size - DO NOT COUNT ANYONE TWICE
For Government Use Only

Persons you are sponsoring in this affidavit:

a. Enter the number you entered on line 10.
0 4

Persons NOT sponsored in this affidavit:

b. Yourself. c. If you are currently married, enter "1" for your spouse. d. If you have dependent children, enter the number here. e. If you have any other dependents, enter the number here. f. If you have sponsored any other persons on an I-864 or I-864 EZ who are now lawful permanent residents, enter the number here. g. OPTIONAL: If you have siblings, parents, or adult children with the same principal residence who are combining their income with yours by submitting Form I-864A, enter the number here. h. Add together lines and enter the number here. Household Size:
1 0 0

1
1 3 0

Part 6. Sponsor's income and employment.

22. I am currently: a. Employed as a/an
DENTAL HYGIENIST

. . . . since .
(Date)

Name of Employer #1 (if applicable) Name of Employer #2 (if applicable) b. c. d. Self-employed as a/an Retired from

BRYAN BONNET DDS

PAUL SUMMER DDS

(Company Name)

Unemployed since

.
(Date)

23. My current individual annual income is:

$ 85,000.00
(See Step-by-Step Instructions)

Form I-864 (Rev. 10/08/10)Y Page 3

24. My current annual household income: a. List your income from line 23 of this form.
$ 85,000.00

For Government Use Only

b. Income you are using from any other person who was counted in your household size, including, in certain conditions, the intending immigrant. (See step-by-step instructions.) Please indicate name, relationship and income. Name Relationship Current Income
$ $ $ $ $

Household Size =

Poverty line for year _______________ is:

c. Total Household Income:

$ 85,000.00

(Total all lines from 24a and 24b. Will be Compared to Poverty Guidelines -- See Form I-864P.)

d.

The persons listed above have completed Form I-864A. I am filing along with this form all necessary Forms I-864A completed by these persons. The person listed above,
(Name)

e.

does not need to

complete Form I-864A because he/she is the intending immigrant and has no accompanying dependents.

25. Federal income tax return information. I have filed a Federal tax return for each of the three most recent tax years. I have attached the required photocopy or transcript of my Federal tax return for only the most recent tax year. My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal tax returns for the most recent three years was: Tax Year
2010 2009 2008

Total Income
(most recent) $
81,446.00 80,903.00 82,961.00

(2nd most recent) $ (3rd most recent) $

(Optional) I have attached photocopies or transcripts of my Federal tax returns for my second and third most recent tax years.

Form I-864 (Rev. 10/08/10)Y Page 4

Part 7. Use of assets to supplement income. (Optional)

If your income, or the total income for you and your household, from line 24c exceeds the Federal Poverty Guidelines for your household size, YOU ARE NOT REQUIRED to complete this Part. Skip to Part 8. 26. Your assets (Optional) a. Enter the balance of all savings and checking accounts. b. Enter the net cash value of real-estate holdings. (Net means current assessed value minus mortgage debt.) c. Enter the net cash value of all stocks, bonds, certificates of deposit, and any other assets not already included in lines 26 (a) or (b). d. Add together lines 26 a, b and c and enter the number here. $

For Government Use Only

Household Size =

Poverty line for year _______________ is:

$ $

TOTAL: $

27. Your household member's assets from Form I-864A. (Optional) Assets from Form I-864A, line 12d for $
(Name of Relative)

28. Assets of the principal sponsored immigrant. (Optional) The principal sponsored immigrant is the person listed in line 2. a. Enter the balance of the sponsored immigrant's savings and checking accounts. b. Enter the net cash value of all the sponsored immigrant's real estate holdings. (Net means investment value minus mortgage debt.) c. Enter the current cash value of the sponsored immigrant's stocks, bonds, certificates of deposit, and other assets not included on line a or b. d. Add together lines 28a, b, and c, and enter the number here. 29. Total value of assets. Add together lines 26d, 27 and 28d and enter the number here. TOTAL: $ $ $

$ $
The total value of all assests, line 29, must equal 5 times (3 times for spouses and children of USCs, or 1 time for orphans to be formally adopted in the U.S.) the difference between the poverty guidelines and the sponsor's household income, line 24c.

Form I-864 (Rev. 10/08/10)Y Page 5

Part 8. 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 and other Federal laws. The following paragraphs describe those obligations. Please read the following information carefully before you sign the Form I-864. If you do not understand the obligations, you may wish to consult an attorney or accredited representative.
What is the Legal Effect of My Signing a Form I-864?

If you sign a Form I-864 on behalf of any person (called the "intending immigrant") who is applying for an immigrant visa or for adjustment of status to a permanent resident, and that intending immigrant submits the Form I-864 to the U.S. Government with his or her application for an immigrant visa or adjustment of status, under section 213A of the Immigration and Nationality Act these actions create a contract between you and the U. S. Government. The intending immigrant's becoming a 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 an alien likely to become a public charge, the U.S. Government can consider your income and assets to be available for the support of the intending immigrant.
What If I choose Not to Sign a Form I-864?

You cannot be made to sign a Form 1-864 if you do not want to do so. But if you do not sign the Form I-864, the intending immigrant may not be able to become a permanent resident in the United States.
What Does Signing the Form I-864 Require Me to do?

If an intending immigrant becomes a permanent resident in the United States based on a Form I-864 that you have signed, then, until your obligations under the Form I-864 terminate, you must: -- Provide the intending immigrant any support necessary to maintain him or her at an income that is at least 125 percent of the Federal Poverty Guidelines for his or her household size (100 percent if you are the petitioning sponsor and are on active duty in the U.S. Armed Forces and the person is your husband, wife, unmarried child under 21 years old.) -- Notify USCIS of any change in your address, within 30 days of the change, by filing Form I-865.
What Other Consequences Are There?

If an intending immigrant becomes a permanent resident in the United States based on a Form I-864 that you have signed, then until your obligations under the Form I-864 terminate, your income and assets may be considered ("deemed") to be available to that person, in determining whether he or she is eligible for certain Federal means-tested public benefits and also for State or local means-tested public benefits, if the State or local government's 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(c) of the Welfare Reform Act such as, but not limited to, 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.

Contract continued on following page.

Form I-864 (Rev. 10/08/10)Y Page 6

What If I Do Not Fulfill My Obligations?

If you do not provide sufficient support to the person who becomes a permanent resident based on the Form I-864 that you signed, that person may sue you for this support. If a Federal, State or local agency, or a private agency provides any covered means-tested public benefit to the person who becomes a permanent resident based on the Form I-864 that you signed, the agency may ask you to reimburse them for the amount of the benefits they provided. If you do not make the reimbursement, the agency may sue you for the amount that the agency believes you owe. If you are sued, and the court enters a judgment against you, the person or agency that sued you may use any legally permitted procedures for enforcing or collecting the judgment. You may also be required to pay the costs of collection, including attorney fees. If you do not file a properly completed Form I-865 within 30 days of any change of address, USCIS may impose a civil fine for your failing to do so.
When Will These Obligations End?

Your obligations under a Form I-864 will end if the person who becomes a permanent resident based on a Form I-864 that you signed: Becomes a U.S. citizen; Has worked, or can be credited with, 40 quarters of coverage under the Social Security Act; No longer has lawful permanent resident status, and has departed the United States; Becomes subject to removal, but applies for and obtains in removal proceedings a new grant of adjustment of status, based on a new affidavit of support, if one is required; or Dies. Note that divorce does not terminate your obligations under this Form I-864. Your obligations under a Form I-864 also end if you die. Therefore, if you die, your Estate will not be required to take responsibility for the person's support after your death. Your Estate may, however, be responsible for any support that you owed before you died.

30. I, LOC PHAN

(Print Sponsor's Name)

certify under penalty of perjury under the laws of the United States that:

a. I know the contents of this affidavit of support that I signed. b. All the factual statements in this affidavit of support are true and correct. c. I have read and I understand each of the obligations described in Part 8, and I 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 permanent residents of the United States; lawsuit against me to enforce my obligations under this Form I-864;

d. I agree to submit to the personal jurisdiction of any Federal or State court that has subject matter jurisdiction of a e. Each of the Federal income tax returns submitted in support of this affidavit are true copies, or are unaltered tax
transcripts, of the tax returns I filed with the U.S. Internal Revenue Service; and Sign on following page.
Form I-864 (Rev. 10/08/10)Y Page 7

f.

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.

g. Any and all other evidence submitted is true and correct. 31.
(Sponsor's Signature) (Date-- mm/dd/yyyy)

Part 9. Information on Preparer, if prepared by someone other than the sponsor.

I certify under penalty of perjury under the laws of the United States that I prepared this affidavit of support at the sponsor's request and that this affidavit of support is based on all information of which I have knowledge. Signature: Printed Name: Firm Name: Address: Telephone Number: E-Mail Address : Business State ID # (if any)
Date:
(mm/dd/yyyy)

Form I-864 (Rev. 10/08/10)Y Page 8