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USCIS

Form I-864A

Contract Between Sponsor and Household Member
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0075
Expires 07/31/2017

For Government Use Only
This Form I-864A relates to a household member who:
IS the intending
immigrant

IS NOT the
intending
immigrant

Reviewed By:
Location:

Date (mm/dd/yyyy):

► START HERE - Type or print in black ink.

Part 1. Information About You (the Household
Member)
Full Name

Physical Address
4.a. Street Number
and Name
4.b.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Apt.

Ste.

Flr.

4.c. City or Town
4.d. State

4.e. ZIP Code

1.c. Middle Name
4.f.

Mailing Address

4.g. Postal Code

2.a. In Care Of Name

4.h. Country

2.b. Street Number
and Name
2.c.

Apt.

Other Information
Ste.

Flr.
5.

2.d. City or Town
2.e. State

Province

Date of Birth

(mm/dd/yyyy)

Place of Birth
2.f.

ZIP Code

6.a. City or Town

2.g. Province
6.b. State or Province
2.h. Postal Code
2.i.

Country

3.

Is your current mailing address the same as your physical
address?
Yes
No

If you answered "No" to Item Number 3., provide your
physical address.

Form I-864A 07/02/15 N

6.c. Country

7.

U.S. Social Security Number (if any)

8.

USCIS ELIS Account Number (if any)

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3rd Most Recent $ Parent Brother or sister Other dependent (Specify) (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third most recent tax years. Part 3. Your (the Household Member's) Relationship to the Sponsor Part 4. 2nd Most Recent $ Son or daughter (at least 18 years of age) 2. Self employed as a/an 1. $ (mm/dd/yyyy) Unemployed since (mm/dd/yyyy) My current individual annual income is: $ Form I-864A 07/02/15 N Page 2 of 8 . certificates of deposit.a. Enter the net cash value of real-estate holdings. 2. 3.a. or 3. 1.Part 2. Your (the Household Member's) Employment and Income I am currently: 1. I am not the intending immigrant. Name of Employer Number 2 (if applicable) 1. and other assets not listed on Item Numbers 3.d.a.b. 1. 3. Enter the balance of all cash.. Retired from (Company Name) Since 1.b. savings.b.2. (Net value means assessed value minus mortgage debt. 1.a.c. I am the intending immigrant and also the sponsor's spouse. bonds.. 3. 1.. My assets (complete only if necessary).b. Your (the Household Member's) Federal Income Tax Information and Assets Select Item Number 1.d. 1. or 1.. Enter the cash value of all stocks. I am the intending immigrant and also a member of the sponsor's household.c.c. I am related to the sponsor as his/her: I have filed a Federal income tax return for each of the three most recent tax years. and 3.a.c. My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal income tax returns for the most recent three years was: Tax Year Total Income 2. and checking accounts. I have attached the required photocopy or transcript of my Federal income tax return for only the most recent tax year.b. I am the sponsor's household member. $ 1.b.) $ 3. Most Recent $ Spouse 2.c. 1.a. Add together Item Numbers 3.a.c.1. Employed as a/an Name of Employer Number 1 (if applicable) $ 3.b. and enter the number here.a.a.

Name . USCIS ELIS Account Number (if any) ► Intending Immigrant Number 3: I.S. Date of Birth 3. U. Family Name (Last Name) 21. Social Security Number (if any) (mm/dd/yyyy) ► 5.a.a. 11. Given Name (First Name) 11.b. Part 5. Date of Birth 13.c. Given Name (First Name) Intending Immigrant Number 4: Name 1. Middle Name 12.a. Middle Name 7.9.S. Family Name (Last Name) 6.b.c. Statement.c. Date of Birth (mm/dd/yyyy) 8. Certification.a. A-Number (if any) ► A- 14. Middle Name 17. USCIS ELIS Account Number (if any) ► USCIS ELIS Account Number (if any) ► Intending Immigrant Number 2: 16. Family Name (Last Name) 16. Given Name (First Name) 21. 6. 1. Given Name (First Name) 16. Given Name (First Name) (mm/dd/yyyy) USCIS ELIS Account Number (if any) ► Intending Immigrant Number 5: Name 6.b. U.b.a. THE SPONSOR. A-Number (if any) ► A- Form I-864A 07/02/15 N 21. Middle Name Page 3 of 8 . Social Security Number (if any) ► Name 20.b.S. Sponsor's Promise. Family Name (Last Name) 1. Contact Information. NOTE: Read the information on penalties in the Penalties section of the Form I-864A Instructions before completing this part.c.S. Middle Name 2. Date of Birth 18. Family Name (Last Name) 11. (Print Name) in consideration of the household member's promise to support the following intending immigrant(s) and to be jointly and severally liable for any obligations I incur under the affidavit of support. promise to complete and file an affidavit of support on behalf of the following named intending immigrant(s). A-Number (if any) ► A- 4. A-Number (if any) ► A- 19.c. U. Social Security Number (if any) ► 10. and Signature U. Social Security Number (if any) (Indicate Number) Intending Immigrant Number 1: (mm/dd/yyyy) ► Name 15.

has also read to me every question and instruction on this contract. and have provided complete. Sponsor's Promise. and correct responses in the language indicated above. Form I-864A 07/02/15 N Promise to provide any and all financial support necessary to assist the sponsor in maintaining the sponsored immigrants at or above the minimum income provided for in section 213A(a)(1)(A) of the Immigration and Naturalization Act (INA) (not less than 125 percent of the Federal Poverty Guidelines) during the period in which the affidavit of support is enforceable. or 26. USCIS ELIS Account Number (if any) ► I certify. and correct. I authorize the release of any information from any and all of my records that USCIS or the Department of State may need to determine my eligibility for the immigration benefit that I seek. Furthermore. (Print Name) Sponsor's Contact Information 28.b. Sponsor's Promise. under penalty of perjury. Certification. true. who is is not an attorney or accredited 31. (Print number of intending immigrants noted in Part 5. that the information in my contract and any document submitted with my contract were provided by me and are complete. If applicable. preparing this contract for me. Sponsor's Statement NOTE: Select the box for either Item Number 26. I can read and understand English. and in my USCIS or Department of State record to other entities and persons where necessary for the administration and enforcement of U. 26. select the box for Item Number 27. Certification. 27. in I have requested the services of and consented to .S.b. THE HOUSEHOLD MEMBER. representative. Date of Signature (mm/dd/yyyy) . and I understand that USCIS or the Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Sponsor's Mobile Telephone Number (if any) 30. Sponsor's Email Address (if any) in consideration of the sponsor's promise to complete and file an affidavit of support on behalf of the above named intending immigrants.) A. Statement. Social Security Number (if any) I furthermore authorize release of information contained in this contract. . A-Number Copies of any documents I have submitted are exact photocopies of unaltered. and Signature.a. The interpreter named in Part 7. Certification.Sponsor's Certification Part 5. immigration laws. Contact Information. Sponsor's Daytime Telephone Number 29. true. and have read and understand every question and instruction on this contract. Your (the Household Member's) Promise.b. I understand every question and instruction on this contract as translated to me by my interpreter. Sponsor's Signature Part 6. ► 25. Page 4 of 8 . and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-864A Instructions before completing this part. a language in which I am fluent.S. I. 26. U. in supporting documents. Contact Information. original documents. Statement. Date of Birth 23.a. Contact Information. as well as my answer to every question. and Signature (continued) 22. (mm/dd/yyyy) ► A- 24. as well as my answer to every question. Statement. Sponsor's Signature 31.a.

to any agency of the Federal Government. as well as my answer to every question. Consideration where the household member is also the sponsored immigrant: I understand that if I am the sponsored immigrant and a member of the sponsor's household that this promise relates only to my promise to be jointly and severally liable for any obligation owed by the sponsor under the affidavit of support to any of my dependents. and have provided complete. Statement. Certification. dissolution.a. 1.a. to any agency of the Federal Government. Your (the Household Member's) Email Address (if any) Your (the Household Member's) Certification Copies of any documents I have submitted are exact photocopies of unaltered. Certify under penalty under the laws of the United States that the Federal income tax returns submitted in support of the contract are true copies or unaltered tax transcripts filed with the Internal Revenue Service. I furthermore authorize release of information contained in this contract. C.S. Agree to be jointly and severally liable for payment of any and all obligations owed by the sponsor under the affidavit of support to the sponsored immigrants. and to provide any and all financial support necessary to assist the sponsor in maintaining any of my dependents at or above the minimum income provided for in section 213A(a)(1)(A) of the INA (not less than 125 percent of the Federal Poverty Guideline) during the period which the affidavit of support is enforceable. in supporting documents. annulment. E. as well as my answer to every question. has also read to me every question and instruction on this contract. F. or to any other private entity that provides means-tested public benefits. Your (the Household Member's) Mobile Telephone Number (if any) 5.b. if I am related to the sponsored immigrant or the sponsor by marriage. I understand every question and instruction on this contract as translated to me by my interpreter. to any agency of a state or local government. who is is not an attorney or accredited representative. I understand that.Part 6. and have read and understand every question and instruction on this contract. Your (the Household Member's) Daytime Telephone Number 4. the termination of the marriage (by divorce. original documents.b. If applicable. in . I have requested the services of and consented to . Your (the Household Member's) Contact Information 3. to any agency of a state or local government. immigration laws. D. or 1. Contact Information. 2. 1. or other legal process) will not relieve me of my obligations under this Form I-864A. and in my USCIS or the Department of State record to other entities and persons where necessary for the administration and enforcement of U. I authorize the release of any information from any and all of my records that USCIS or the Department of State may need to determine my eligibility for the immigration benefit that I seek. preparing this contract for me. Your (the Household Member's) Promise. true. and I understand that USCIS or the Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Your (the Household Member's) Statement NOTE: Select the box for either Item Number 1. Citizenship and Immigration Services (USCIS). I can read and understand English. Form I-864A 07/02/15 N Page 5 of 8 . and Signature (continued) B. Furthermore. select the box for Item Number 2. I authorize the Social Security Administration to release information about me in its records to the Department of State and U. a language in which I am fluent.S. The interpreter named in Part 7. and correct responses in the language indicated above.

Certification. Interpreter's Contact Information. Preparer's Business or Organization Name (if any) 3. Your (the Household Member's) Signature 6. Postal Code 1. Certification. Statement. State 3.f.. and Signature (continued) I certify.c. Certification. Part 8. ZIP Code Province 3. Contact Information. Date of Signature (mm/dd/yyyy) 2.g.a. that the information in my contract and any document submitted with my contract were provided by me and are complete.b. Flr.a. and The sponsor and household member have informed me that he and/or she understands every instruction and question on the contract. as well as the answer to every question.a. Ste.a. Interpreter's Signature 1.b.. and the sponsor and household member verified the accuracy of every answer.b.c.. Interpreter's Signature 1.. Date of Signature (mm/dd/yyyy) Part 7. Your (the Household Member's) Promise.b. Contact Information.Part 6. and Signature of the Person Preparing this Contract. under penalty of perjury.d. Your (the Household Member's) Printed Name I certify that: 6. Interpreter's Family Name (Last Name) 6.h. 3. Interpreter's Daytime Telephone Number 5.b. Interpreter's Given Name (First Name) 6. Apt. Country Form I-864A 07/02/15 N Page 6 of 8 . I have read to this sponsor and household member every question and instruction on this contract. true. If Other Than the Household Member Preparer's Full Name 1. Preparer's Given Name (First Name) 2. and Signature Provide the following information about the interpreter.e. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.b. Item Number 26. Provide the following information about the preparer. Interpreter's Contact Information 4. and correct. Statement.a.b. Street Number and Name 3. City or Town 3. Interpreter's Email Address (if any) Your (the Household Member's) Signature Interpreter's Certification 6. . Item Number 26. in the language provided in Part 5. Preparer's Family Name (Last Name) 3. Interpreter's Full Name I am fluent in English and which is the same language provided in Part 5. as well as the answer to every question.

and with the household member and sponsor's consent. ZIP Code Province Preparer's Certification By my signature. Apt. who agreed with every answer on the contract. I am not an attorney or accredited representative but have prepared this contract on behalf of the household member and sponsor. Notice of Entry of Appearance as Attorney or Accredited Representative. Preparer's Signature 3. you must submit a completed Form G-28. 7.b.a. that I prepared this contract on behalf of. with this contract. City or Town 3. at the request of. State 3. Flr.h. and with the express consent of the household member and sponsor. I reviewed it and all of the household member's and sponsor's responses with the household member and sponsor. Date of Signature (mm/dd/yyyy) Preparer's Contact Information 4. Form I-864A 07/02/15 N Page 7 of 8 . I completed this contract based only on responses the household member and sponsor provided to me. 3.a.b. Preparer's Email Address (if any) Preparer's Statement 7. and Signature of the Person Preparing this Contract. Preparer's Daytime Telephone Number 5. Statement.c. Certification. After completing the contract. I certify. Ste. swear. Postal Code 3. Country 8.d. Street Number and Name 3. or affirm. If the household member or sponsor supplied additional information concerning a question on the contract. 3.f.Part 8. If Other Than the Household Member (continued) Preparer's Mailing Address 3.a. Contact Information.b. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this contract. Preparer's Signature 8.g. Preparer's Fax Number 6. I recorded it on the contract. under penalty of perjury. I am an attorney or accredited representative and my representation of the household member and sponsor in this case extends does not extend beyond the preparation of this contract.e.

a. Item Number 5. Part Number 5. Part Number 4.d.a. A-Number (if any) A3.c. Part Number 3. Item Number 4. If you need more space than what is provided.b.b.d. Include your name and A-Number (if any) at the top of each sheet.b.b. Page Number Part 9. Part Number. you may make copies of this page to complete and file with this contract or attach a separate sheet of paper. indicate the Page Number.c. Item Number 6. Additional Information If you need extra space to provide any additional information within this contract. Page Number 6. 3. Item Number 6.a. Middle Name 2. Given Name (First Name) 1. and sign and date each sheet. and Item Number to which your answer refers.a. Page Number 4. 1. 4.c. use the space below. Form I-864A 07/02/15 N Page 8 of 8 .5. Page Number 3. 5.c. Part Number 6.a.c. Family Name (Last Name) 1.d.d.b.