Psicologa

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 09/30/2012

Part 1. Basis for filing Affidavit of Support.
1. I, David Jimenez 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. (Checkappropriate 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 theprincipal immigrant.
2. Last Name First Name
Sandra RIVERA

Middle Name
Milena

3. Mailing Address Street Number and Name (Include Apartment Number)
4041 Collins Ave #503

City

State/Province

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

4. Country of Citizenship
Colombia

Miami Beach

FL

6. Alien Registration Number (if any) A- None 8. 9.

7. U.S. Social SecurityNumber (if any)
None

10/15/1989

Number of Affidavits of Support in file: 1 2

Part 3. Information on the immigrant(s) you are sponsoring.
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 inPart 2 above. Do not include any relative listed on a separate visa petition.
Name
a. b. c. d. e.

Relationship to Sponsored Immigrant

Date of Birth
(mm/dd/yyyy)

A-Number (if any)

U.S.Social Security Number (if any)

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

0

1

Form I-864 (09/19/11) Y

Part 4. Information onthe Sponsor.
11. Name
Last Name First Name

Jimenez David

For Government Use Only Middle Name

12. Mailing Address

Street Number and Name (Include Apartment Number)

--

City

State or Province

Country

Zip/Postal Code

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

CountryZip/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
620-46-1437 10/07/1962

US

State or Province

Country
Colombia

Form I-864 (09/19/11) Y Page 2

Part 5. Sponsor's household size.
21. YourHousehold 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 1

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....