Fill and Sign the Ohsu Body Donation Form

OMB No. 1615-0075; Expires 09/30/06 I-864W, Intending Immigrant's Affidavit of Support Exemption Department of Homeland Security U.S. Citizenship and Immigration Services Instructions How Should I Complete This Form? Print clearly or type your answers using CAPITAL letters. Use black or blue ink. If you are claiming credit for quarters worked by a spouse or parent, you may not count any quarter in which the spouse or parent was receiving means-tested public benefits. Include all SSA forms necessary to establish that you have or can be credited with 40 quarters of coverage. If you need extra spact to answer any item: -- Attach a seperate sheet of paper (or more sheets if necessary); and -- Write your name, Social Security number and the words "Form I-864W" on the top right corner of the sheet; and write the number and subject of each question for which you are providing additional information. What Is the Purpose of This Form? The Form I-864 is legally required for many family-based immigrants and some employment-based immigrants to show that they have adequate means of financial support and that they are not likely to become a public charge. Certain classes of immigrants are exempt from the I-864 requirement and therefore must file Form I-864W instead of Form I-864 or Form I-864EZ. For more information abut Forms I-864, I-864EZ, or I-864W, or to obtain related forms please contact: The USCIS Website (www.uscis.gov); The National Customer Service Center (NCSC) telephone line at 1-800-375-5283 TTY: (1-800-767-1833); or Your local USCIS office by using InfoPass. How Is This Form Used? You must use this form instead of Form I-864 with your application for an immigrant visa or adjustment of status if any of the following apply: (1) You have earned (or can be credited with) 40 quarters of coverage under the Social Security Act (SSA). If you have 40 quarters or SSA coverage, you are exempt from the requirement to file Form I-864. You can acquire 40 qualifying quarters in the following ways: Working in the United States for 40 quarters in which you received the minimum income established by the Social Security Administration; or By being credited under section 213(a)(3)(B) of the Immigration and Nationality Act with quarters worked by your spouse during the marriage or a parent during the time you were under 18 years of age; or A combination of the above. (2) Intending immigrant is a child who will become a U.S. citizen immediately upon entry under the Child Citizenship Act of 2000 (CCA). Under the CCA, some children become U.S. citizens immediately upon admission to the United States or adjustment of status to that of a lawful permanent resident. For this classification to apply: At least one parent of the child is a U.S. citizen; The child is under 18 years of age at the time of admission or adjustment of status; The child is residing permanently in the United States in the legal and physical custody of the U.S. parent; and If the child is an alien orphan child adopted abroad, the adoption was legally finalized prior to admission to the United States and both adoptive parents or the unmarried U.S. citizen parent personally observed the alien orphan before or during the adoption proceeding. If the citizen parent(s) adopted the alien orphan abroad, but at least one of the adoptive parents or the unmarried parent did not see and observe the alien orphan before or during the foreign adoption proceeding, then an affidavit of support under this part is still required unless the citizen parent submits evidence that, under the law of the state of the alien orphan's intended residence in the United States, the foreign adoption decree is entitled to recognition without the need for a formal administrative or judicial proceeding in the State of proposed residence. Orphans whose adoptions are not legally finalized until after admission to the United States will not qualify for this exemption and must file a Form I-864. (3) You are filing for an immigrant visa as a selfpetitioning widow(er). If you are filing as a selfpetitioning widow(er) using Form I-360, you are exempt from the Affidavit of Support requirements if your Form I-360 is approved and you are applying for lawful permanent residence. (4) You are filing for an immigrant visa as a self-petitioning battered spouse or child. If you are filing as a selfpetitioning battered spouse or child using Form I-360, you are exempt from the Affidavit of Support requirements if your Form I-360 is approved and you are applying for lawful permanent residence. Form I-864W (01/15/06)N Other Information. Penalties. The Government may pursue verification of any information provided on or in support of this form. If you include in this affidavit of support any information that you know to be false, you may be liable for criminal prosecution under the laws of the United States. Privacy Act Notice. Authority for the collection of the information requested on this form is contained in 8 U.S.C. 1182a(4), 1183a, 1184(a), and 1258. The information will be used principally by an immigration judge, USCIS, or a Consular Officer to whom it is furnished, to determine an alien's eligibility for benefits under the Immigration and Nationality Act, specifically whether he or she has adequate means of financial support and will not become a public charge. Submission of the information is voluntary. Failure to provide the information will result in denial of the application for an immigrant visa or adjustment of status. Reporting Burden. A person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. The estimated average time to complete and file this form is as follows: (1) 15 minutes to learn about the law and form; (2) 15 minutes to complete the form; and (3) 30 minutes to assemble and file the form; for a total estimated average of 1 hour per form. If you have comments regarding the accuracy of this estimate or suggestions for making this form simpler, write to U.S. Citizenship and Immigration Services, Regulatory Management Division, Attn: OMB No. 1615-0075, 111 Massachusetts Avenue N.W., Washington, D.C. 20529. Do not mail your completed form to this address The information may also, as a matter of routine use, be disclosed to other Federal, State and local agencies providing means-tested public benefits for use in civil action against the sponsor for breach of contract. Social Security numbers may be verified with the Social Security Administration consistent with the consent signed as part of the contract in Part 3 of the Form I-864. They may also be disclosed as a matter of routine use to other Federal, State, local, and foreign law enforcement and regulatory agencies to enable these entities to carry out their law enforcement responsibilities. USCIS Forms and Information. To order USCIS forms, call our toll-free forms line at 1-800-870-3676. You can also obtain forms and information on immigration laws, regulations and procedures by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our internet website at www.uscis.gov. Use InfoPass for Appointments. As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through our internet-based system, InfoPass. To access the system, visit our website at www.uscis.gov. Use the InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen. Print the notice and take it with you to your appointment. The notice gives the time and date of your appointment, along with the address of the USCIS office. Form I-864W Instructions (Rev. 01/15/06)N Page 2 OMB No. 1615-0075; Expires 09/30/06 I-864W, Intending Immigrant's Affidavit of Support Exemption Department of Homeland Security U.S. Citizenship and Immigration Services Part 1. Information about the intending immigrant. (You or your adopted child.) For Government Use Only Last Name 1. Name First Name Middle Name Street Number and Name (include apartment number) 2. Address City State or Province Country This I-864W: does not meet the requirements of exemption. Zip/Postal Code 3. Date of Birth (mm/dd/yyyy) 4. Country of Birth (city/country) 5. Telephone Number meets the requirements of exemption. (Include area code or country and city codes) 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. I am filing for an immigrant visa or adjustment of status as a battered spouse or child using 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) (Date--mm/dd/yyyy) Form I-864W (Rev. 01/15/06)N