Fill and Sign the Tcpa Building Permit Application Form

OMB No. 1615-0075; Expires 03/31/2015 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.) Last Name 1. Name For Government Use Only First Name 2. Address Middle Name Street Number and Name (include apartment number) 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 (03/22/13) Y