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I-944, Declaration of Self-Sufficiency Checklist & Questionnaire

Required Documentation

If you have ever been arrested in the U.S. or another country, please disclose to our office immediately so that our office can best represent you.

Petitioner/Sponsor Documents (if applicable)

☐ Proof of citizenship

☐ Proof of relationship (marriage certificate, birth certificate, etc.)

☐ Affidavit of Support (drafted by Challa Law Group and signed by sponsor)

☐ Proof of current income for yourself and household members including (but not limited to):

☐ Copy of W-2s

☐ Copy of 1099s

☐ Employer letter (including job title, salary, benefits, deductions) ☐ Pay stubs (3 most recent)

☐ Evidence of Assets:

☐ Real Estate deeds, appraisal or mortgage documents showing equity

☐ Checking account statements for 12 months prior

☐ Savings account statements for 12 months prior

☐ Annuities showing monthly payments ☐ Stocks and bonds (cash value)

☐ Certificates of Deposit

☐ Retirement account statements for 12 months prior

☐ Educational account statements for 12 months prior

☐ Net cash value of real estate holdings

☐ Automobiles (if two or more)

☐ Other evidence of substantial assets

Beneficiary Documents

☐ Social Security earnings and benefits statement (if beneficiary has worked for 40 qualifying quarters in the U.S.)

☐ Income tax from abroad, if last employment was abroad

☐ Proof of employment

☐ Employment verification letter

☐ Letter offering employment

☐ W-2s ☐ Most recent pay stubs for current year

☐ Documentation of liabilities and debts:

☐ Mortgages

☐ Car loans

☐ Medical debt ☐ Unpaid child or spousal support

☐ Unpaid taxes

☐ Credit card debt

☐ Other debts and liabilities

☐ Judgments and bankruptcies:

☐ Copies of any filings for bankruptcies

☐ Copies or information of any judgments

☐ Credit report and credit score (or evidence from credit bureau that proves no U.S. credit report exists)

☐ Evidence of Assets:

☐ Real Estate deeds, appraisal or mortgage documents showing equity

☐ Checking account statements for 12 months prior

☐ Savings account statements for 12 months prior

☐ Annuities showing monthly payments ☐ Stocks and bonds (cash value)

☐ Certificates of Deposit

☐ Retirement account statements for 12 months prior

☐ Educational account statements for 12 months prior

☐ Net cash value of real estate holdings

☐ Automobiles (if two or more)

☐ Other evidence of substantial assets

☐ Evidence of health insurance:

☐ Policy Declaration Page

☐ Proof of deductible or annual premium amount ☐ Copy of IRS Form 8962 or Form 1095A if you received a Premium Tax Credit or Advanced Premium Tax Credit

☐ Proof of when insurance terminates or must be renewed

☐ Enrollment terms and type of coverage

☐ Form 1095-B Health Coverage; 1095C Employer Provided Health Insurance Offer and Coverage with evidence of renewal or coverage for the current year

☐ Additional income documents for yourself and household members including (but not limited to):

☐ Child Support

☐ Social Security ☐ Unemployment Benefits

☐ Documents showing receipt of public benefits, including:

☐ Any Federal, State, local, or tribal cash assistance for income maintenance ☐ Supplemental Security Income (SSI) ☐ Temporary Assistance for Needy Families (TANF) ☐ Federal, State or local cash benefit programs for income maintenance (called “General Assistance” or under other names) ☐ Supplemental Nutrition Assistance Program (SNAP, or “Food Stamps”) ☐ Section 8 Housing Assistance under the Housing Choice Voucher Program

☐ Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation) ☐ Public Housing under the Housing Act of 1937 ☐ Federally funded Medicaid.

☐ Documents showing education and skills:

☐ Transcripts, diplomas, degrees and trade certificates ☐ If a current student, evidence of full-time studies ☐ If foreign degree – Credentials Evaluation ☐ Training certificates and/or licenses for any specific occupations or professions ☐ Certifications or courses in English and other languages in addition to English ☐ Native English speakers - high school diplomas and college degrees for English courses studied for credit

☐ Any records related to criminal charges, arrests, or detainments by law enforcement officers for any reason:

☐ Official statement confirming no charges filed ☐ Copy of complete arrest record and/or disposition for each incident ☐ Sentencing record for each incident

☐ Probation or parole record

☐ Probation Evidence of alternative sentencing program or rehabilitative program

☐ Court order vacating, setting aside, sealing, expunging or otherwise removing the arrest or conviction or a statement from the court that no record exists of your arrest or conviction

Required Biographic Information – Applicant

First Name (Given Name) Middle Name Last Name (Family Name/Surname)

☐ Check here if you completed the below biographic and mailing address information on the I-485 questionnaire and then skip to the Household Information section.

Alien Registration Number (A-Number, if any)

USCIS Online Account Number (if any)

Date of Birth City or Town of Birth

Country of BirthCountry of Citizenship or Nationality


IRS Tax Number (if any)

Current Mailing AddressIn Care of Name (if any)

Street Number and Name

☐ Apt☐ Ste.☐ Flr.

Number

City or Town

State Zip Code + 4

Household Information

Your household includes yourself, your spouse (if physically residing with you), your children (under age of 21, unmarried, and physically residing with you), other children (under the age of 21, unmarried,

not residing with you but for whom you provide at least 50% financial support per written agreement or order), other individuals to whom you provide at least 50% financial support or who are listed as

dependents on federal tax returns

There is space for ten household members below. Use additional pages if needed or disregard the additional slots if there are fewer household members. Regular questions resume on page 23.

Household Member #1 (Self)


Date of Birth Relationship to You ☐ Self


Does this individual earn income? (Including income from employment, child support, spousal support, retirement benefits, or unemployment compensation?)

If yes, please provide the following:

☐ Yes☐ No

Current Income Source of Income

Year of most recent tax return, if any

Income reported on most recent tax return

If this individual did not file, select the reason for not filing and provide an explanation.

☐ Plan to file the tax return before the due date for this year☐ Not required to file a tax return (provide explanation)☐ Filed for an extension☐ Not going to file (provide an explanation)☐ Other:

Explanation for not filing a tax return

If this individual received additional income on a continuing weekly, monthly, or annual basis during the most recent tax year, and the income is NOT listed on the tax return, provide the amount of additional income (example: child support).

Type of Additional Income

Annual Amount Received

Will this individual continue to receive this income in the future? (mm/dd/yyyy)

☐ Yes☐ No

When do you anticipate this additional income will no longer be received?

What is the total annual amount of additional income received at the time of filing?

Is any of the additional income listed above from an illegal activity or source (such as illegal gambling or drug sales)?

☐ Yes☐ No

If yes, what amount of additional income listed above is from an illegal activity?

Please provide this individual’s assets and cash value in U.S. dollars.

Type of Asset Asset Value in U.S. Dollars

Checking – Bank Account

Savings – Bank Account

Stocks, Bonds, Certificates of Deposit

Retirement or Educational Account

Real Estate Holdings

Other

Household Member #2


Date of Birth Relationship to You

☐ Spouse☐ Child☐ Parent☐ Other Individual


Does this individual live with you? ☐ Yes☐ No

Is this individual filing an application for an immigration benefit with you or has this individual already filed an application?

☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #3







☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #4


Date of Birth Relationship to You ☐ Spouse☐ Child

☐ Parent☐ Other Individual




☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No



Is any of the additional income listed above from an illegal activity or ☐ Yes

source (such as illegal gambling or drug sales)? ☐ NoIf yes, what amount of additional income listed above is from an illegal activity?








Other

Household Member #5







☐ Yes☐ No


☐ Yes☐ No












☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #6







☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #7







☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No












Other

Household Member #8







☐ Yes☐ No


☐ Yes☐ No












☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #9







☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No




☐ Yes☐ No









Other

Household Member #10







☐ Yes☐ No



☐ Yes☐ No











☐ Yes☐ No












Other

Total number of household members (including yourself)

Liabilities/Debt InformationType of Liability or Debt Amount Owed

in U.S. Dollars

Mortgages

Car Loans

Credit Card Debt

Education Related Loans

Tax Debts

Liens

Personal Loans

Other

TOTAL (U.S. Dollars)

Additional Financial Information

Please apply for a U.S. credit report before answering the following questions. (Learn more at www.usa.gov/credit-reports)

Do you have a U.S. credit score? ☐ Yes☐ No

If yes, provide your most recent credit score

Have you ever filed for bankruptcy, either in the U.S. or in a foreign country?

☐ Yes☐ No

If yes, please provide the following for each bankruptcy filing:

First Bankruptcy Filing

City of Filing State or Country of Filing

Date of Filing (mm/dd/yyyy) Type of Bankruptcy

☐ Chapter 7☐ Chapter 11☐ Chapter 13

Second Bankruptcy Filing




Third Bankruptcy Filing




Health Insurance

Please apply for a U.S. credit report before answering the following questions. (Learn more at www.usa.gov/credit-reports)

Do you currently have health insurance? ☐ Yes☐ No

If yes, did you receive a Premium Tax Credit or Advanced Premium Tax Credit under the Affordable Care Act, for the health insurance?

☐ Yes☐ No

If yes, what is your total annual deductible or annual premium in U.S. dollars?

If yes, when does your health insurance terminate or the date that it must be renewed? (mm/dd/yyyy)

Have you enrolled or will soon enroll in health insurance, but your health coverage has not started yet?

☐ Yes, I am enrolled☐ I will soon enroll☐ No

If you do not have health insurance, please provide an explanation of how you plan to pay for reasonably anticipated medical costs.

Public Benefits

Have you ever received or am currently certified to receive in the future the following benefits:

Any Federal, State, local or tribal cash assistance for income maintenance ☐ Yes☐ No

Supplemental Security Income (SSI) ☐ Yes☐ No

Temporary Assistance for Needy Families (TANF) ☐ Yes☐ No

General Assistance (GA) ☐ Yes☐ No

Supplemental Nutrition Assistance Program (SNAP, formerly called “food stamps)

☐ Yes☐ No

Section 8 Housing Assistance under the Housing Choice Voucher Program

☐ Yes☐ No

Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation)

☐ Yes☐ No

Public Housing under the Housing Act of 1937 ☐ Yes☐ No

Federal-funded Medicaid ☐ Yes☐ No

Have you disenrolled, withdrawn from, or requested to be disenrolled from public benefit(s)?

☐ Yes☐ No

If yes, what is your expected date of disenrollment (mm/dd/yyyy)?

Public Benefits

Type of Public Benefit Agency that Granted Public Benefit

Start Date of Receiving the

Benefit (mm/dd/yyyy)

Date Benefit or Coverage

Ended, Expires, or Expected to

Expire (mm/dd/yyyy)

Amount Received (in U.S. dollars)

Public Benefits (continued)

I am enlisted in the U.S. Armed Forces, or am serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.

☐ Yes☐ No

I am the spouse or child of an individual enlisted in the U.S. Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.

☐ Yes☐ No

At the time I received the public benefits, I (or my spouse or parent) was enlisted in the U.S. Armed Forces, or was serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.

☐ Yes☐ No

At the time I received the public benefits, I was present in the United States in a status exempt from the public charge ground of inadmissibility and I received the public benefits during that time. (If unknown, please provide your immigration status at the time

☐ Yes☐ NoImmigration status at the time you received the benefits:

At the time I received the public benefits, I was present in the United States after being granted a waiver from the public charge ground of inadmissibility.

☐ Yes☐ No

I am the child of U.S. citizens whose lawful admission for permanent residence and subsequent residence in the legal and physical custody of my U.S. citizen parent will result in me automatically acquiring U.S. citizenship upon meeting the eligibility.

☐ Yes☐ No

I am the child of U.S. citizens whose lawful admission for permanent residence will result automatically in my acquisition of citizenship upon finalization of adoption.

☐ Yes☐ No

Have you received, applied for, or been certified to receive federally funded Medicaid in connection with any of the following? (Select all that apply.)

An emergency medical condition ☐ Yes☐ No

For a service under the Individuals with Disabilities Education Act (IDEA)

☐ Yes☐ No

Other school-based benefits or services available up to the oldest age eligible for secondary education under State law

☐ Yes☐ No

While you were under the age of 21 ☐ Yes☐ No

While you were pregnant or during the 60-day period following the last day of pregnancy

☐ Yes☐ No

If yes, please provide the applicable dates.

Start date (mm/dd/yyyy)

End date (mm/dd/yyyy)

Have you ever applied for any of the above public benefits and the application is currently pending or denied?

If yes, please indicate whether the application is pending or was denied below.

☐ Yes☐ No

Pending DeniedNot

Applicable

Any Federal, State, local or tribal cash assistance for income maintenance ☐ ☐ ☐

Supplemental Security Income (SSI) ☐ ☐ ☐

Temporary Assistance for Needy Families (TANF) ☐ ☐ ☐

General Assistance (GA) ☐ ☐ ☐

Supplemental Nutrition Assistance Program (SNAP, formerly called “food stamps) ☐ ☐ ☐

Section 8 Housing Assistance under the Housing Choice Voucher Program ☐ ☐ ☐

Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation) ☐ ☐ ☐

Public Housing under the Housing Act of 1937 ☐ ☐ ☐

Federal-funded Medicaid ☐ ☐ ☐

Date you applied for any of the above listed public benefits (mm/dd/yyyy) ☐ Yes☐ No

Did you withdraw your application(s) before being certified to receive the public benefit?

☐ Yes☐ No

USCIS Fee Waivers

Have you applied for or received a fee waiver when applying for an immigration benefit from USCIS?

☐ Yes☐ No

Date Fee Waiver Received (mm/dd/yyyy) or write N/A if fee

waiver not receivedType of Immigration Benefit (Form

Number) Receipt Number

Education and Skills

Do you have an approved Form I-140 as an alien worker?

If yes, please provide the receipt number.

☐ Yes☐ No

Receipt Number

Have you graduated from high school or earned a high school equivalent diploma (GED)?

☐ Yes☐ No

List your educational history and include all degrees attained.

Program/School Name Degree/Certificate Field of

StudyDate Started (mm/dd/yyyy

)

Date Ended(mm/dd/

yyyy)

Credit Hours/Hours

of Study Completed (if no degree or

certificate completed)

List your occupational skills.

Certification/License Type/Occupational

Skill

Who Issued Your License or

Certification? (if any)

License Number (if any)

Date Obtained (mm/dd/yyyy)

Expiration/Renewal Date, if

any(mm/dd/yyyy)