Fillable I-864a Form I-864A, Contract Between Sponsor and Household Member

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I-864a Form I-864A, Contract Between Sponsor and Household Member

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Contract Between Sponsor and Household Member
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-864A
OMB No. 1615-0075
Expires 10/31/2021
START HERE - Type or print in black ink.►
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
4.d.
State
4.e.
ZIP Code
Country4.h.
Other Information
4.g.
Postal Code
USCIS Online Account Number (if any)
8.
►
Mailing Address
2.d. City or Town
2.e.
State
2.f.
ZIP Code
Country2.i.
2.h.
Postal Code
Street Number
and Name
2.b.
2.c.
Apt. Flr.Ste.
NoYes
Is your current mailing address the same as your physical
address?
3.
If you answered "No" to Item Number 3., provide your
physical address.
5. Date of Birth (mm/dd/yyyy)
City or Town6.a.
Country6.c.
7.
U.S. Social Security Number (if any)
►
Province2.g.
Province4.f.
Place of Birth
State or Province6.b.
This Form I-864A relates to a household member who:
IS the intending
immigrant
IS NOT the
intending
immigrant
For Government Use Only
Date (mm/dd/yyyy):
Reviewed By:
Location:
2.a. In Care Of Name
Physical Address
4.c. City or Town
Street Number
and Name
4.a.
4.b.
Apt. Flr.Ste.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Select this box if
Form G-28 or
G-28I is attached.
Full Name
Part 1. Information About You (the Household
Member)
Page 1 of 8Form I-864A 10/15/19
To be completed by an
attorney or accredited
representative (if any).
(USPS ZIP Code Lookup)
I am not the intending immigrant. I am the sponsor's
household member. I am related to the sponsor as
his/her:
Spouse
Son or Daughter (at least 18 years of age)
Parent
Brother or Sister
Other Dependent (Specify)
I am currently:
Employed as a/an
Self employed as a/an
Retired from (Company Name)
Name of Employer Number 1
Name of Employer Number 2 (if applicable)
Since (mm/dd/yyyy)
Unemployed since (mm/dd/yyyy)
7.
$
My current individual annual income is:
My assets (complete only if necessary).
Add together Item Numbers 3.a., 3.b., and 3.c. and enter
the number here.
3.d.
Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item Numbers 3.a.
or 3.b.
3.c.
Enter the net cash value of real-estate holdings. (Net
value means assessed value minus mortgage debt.)
3.b.
Enter the balance of all cash, savings, and checking
accounts.
3.a.
$
$
$
$
1.c.
1.
4.
5.
6.
2.
3.
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:
Select Item Number 1.a., 1.b., or 1.c.
I am the intending immigrant and also the sponsor's
spouse.
I am the intending immigrant and also a member of
the sponsor's household.
1.a.
1.b.
2.a.
2.b.
2nd Most Recent
3rd Most Recent
Most Recent
Total IncomeTax Year
2.c. $
$
$
NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
tax year.
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
third most recent tax years.
1.b.
NOTE: Read the Penalties section of the Form I-864A
Instructions before completing this part.
I, THE SPONSOR,
in consideration of the household member's promise to support
the following intending immigrants 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 immigrants.
,
(Print Name)
Have you filed a Federal income tax return for each of the
three most recent tax years?
1.a.
NoYes
(Indicate Number)
Part 2. Your (the Household Member's)
Relationship to the Sponsor
Part 3. Your (the Household Member's)
Employment and Income
Part 4. Your (the Household Member's) Federal
Income Tax Information and Assets
Part 5. Sponsor's Promise, Statement, Contact
Information, Declaration, Certification, and
Signature
Page 2 of 8Form I-864A 10/15/19
Intending Immigrant Number 2
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c.
Middle Name
Date of Birth (mm/dd/yyyy)7.
Alien Registration Number (A-Number, if any)
►
A-
8.
Date of Birth (mm/dd/yyyy)2.
Alien Registration Number (A-Number, if any)
►
A-
3.
USCIS Online Account Number (if any)5.
►
4. U.S. Social Security Number (if any)
►
Name
Intending Immigrant Number 1
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Name
Date of Birth (mm/dd/yyyy)17.
Alien Registration Number (A-Number, if any)
►
A-
18.
USCIS Online Account Number (if any)20.
►
Intending Immigrant Number 4
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)
16.c.
Middle Name
19.
U.S. Social Security Number (if any)
►
Name
USCIS Online Account Number (if any)15.
►
14.
U.S. Social Security Number (if any)
►
Intending Immigrant Number 5
21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)
21.c.
Middle Name
Name
USCIS Online Account Number (if any)10.
►
9.
U.S. Social Security Number (if any)
►
Intending Immigrant Number 3
11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
11.c.
Middle Name
Name
Date of Birth (mm/dd/yyyy)12.
Alien Registration Number (A-Number, if any)
►
A-
13.
Date of Birth (mm/dd/yyyy)22.
Alien Registration Number (A-Number, if any)
►
A-
23.
USCIS Online Account Number (if any)25.
►
24. U.S. Social Security Number (if any)
►
Sponsor's Statement
I can read and understand English, and I have read
and understand every question and instruction on this
contract and my answer to every question.
26.a.
NOTE: Select the box for either Item Number 26.a. or 26.b.
If applicable, select the box for Item Number 27.
Part 5. Sponsor's Promise, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Page 3 of 8Form I-864A 10/15/19
I, THE HOUSEHOLD MEMBER,
in consideration of the sponsor's promise to complete and file an
affidavit of support on behalf of the above named intending
immigrants.
(Print number of intending immigrants noted in Part 5.
Sponsor's Promise, Statement, Contact Information,
Declaration, Certification and Signature.)
,
(Print Name)
NOTE: Read the Penalties section of the Form I-864A
Instructions before completing this part.
27.
At my request, the preparer named in Part 8.,
26.b.
The interpreter named in Part 7. read to me every
question and instruction on this contract and my
answer to every question in
a language in which I am fluent, and I understood
everything.
,
,
prepared this contract for me based only upon
information I provided or authorized.
Sponsor's Daytime Telephone Number
Sponsor's Contact Information
28.
29.
30.
Sponsor's Mobile Telephone Number (if any)
Sponsor's Email Address (if any)
Sponsor's Declaration and Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that U.S. Citizenship and Immigration Services (USCIS) or the
U.S. Department of State (DOS) may require that I submit
original documents to USCIS or DOS at a later date.
Furthermore, I authorize the release of any information from
any and all of my records that USCIS or DOS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
contract, in supporting documents, and in my USCIS or DOS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
Sponsor's Signature
(mm/dd/yyyy)Date of Signature31.b.
Sponsor's Signature31.a.
I certify, under penalty of perjury, that all of the information in
my contract and any document submitted with it were provided
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my contract and
that all of this information is complete, true, and correct.
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 the Immigration and
Naturalization Act (INA) section 213A(a)(1)(A)
(not less than 125 percent of the Federal Poverty
Guidelines) during the period in which the affidavit
of support is enforceable;
A.
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, to any agency of the Federal
Government, to any agency of a state or local
government, or to any other private entity that
provides means-tested public benefits;
B.
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;
C.
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, to any agency of the Federal
Government, to any agency of a state or local
government, or to any other private entity that provides
means-tested public benefits 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 INA section 213A(a)
(1)(A) (not less than 125 percent of the Federal Poverty
Guideline) during the period which the affidavit of
support is enforceable.
D.
NOTE TO ALL SPONSORS: If you do not completely fill
out this contract or fail to submit required documents listed in
the Instructions, USCIS may deny your contract.
Part 5. Sponsor's Promise, Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Declaration,
Certification, and Signature
Page 4 of 8Form I-864A 10/15/19
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 (USCIS).
F.
I understand that, if I am related to the sponsored
immigrant or the sponsor by marriage, the
termination of the marriage (by divorce, dissolution,
annulment, or other legal process) will not relieve
me of my obligations under this Form I-864A.
E.
Your (the Household Member's) Declaration and
Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS or DOS may require that I submit original
documents to USCIS or DOS at a later date. Furthermore, I
authorize the release of any information from any and all of my
records that USCIS or DOS may need to determine my
eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
contract, in supporting documents, and in my USCIS or DOS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that all of the information in
my contract and any document submitted with it were provided
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my contract and
that all of this information is complete, true, and correct.
2.
At my request, the preparer named in Part 8.,
1.b.
The interpreter named in Part 7. read to me every
question and instruction on this contract and my
answer to every question in
a language in which I am fluent, and I understood
everything.
,
,
prepared this contract for me based only upon
information I provided or authorized.
Your (the Household Member's) Statement
I can read and understand English, and I have read
and understand every question and instruction on this
contract and my answer to every question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
Your (the Household Member's) Daytime Telephone
Number
Your (the Household Member's) Contact
Information
3.
4.
5.
Your (the Household Member's) Mobile Telephone
Number (if any)
Your (the Household Member's) Email Address (if any)
Your (the Household Member's) Signature
(mm/dd/yyyy)Date of Signature6.c.
Your (the Household Member's) Signature
6.b.
6.a. Your (the Household Member's) Printed Name
NOTE TO ALL HOUSEHOLD MEMBERS: If you do not
completely fill out this contract or fail to submit required
documents listed in the Instructions, USCIS may deny your
contract.
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Declaration,
Certification, and Signature (continued)
Part 7. Interpreter's Contact Information,
Certification, and Signature
Page 5 of 8Form I-864A 10/15/19
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
3.g.
Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
Interpreter's Certification
I certify, under penalty of perjury, that:
which is the same language specified in Part 5., Item
Number 26.b. or Part 6., Item Number 1.b., and I have read
to this sponsor or household member in the identified language
every question and instruction on this contract and his or her
answer to every question. The sponsor or household member
informed me that he or she understands every instruction,
question, and answer on the contract, including the Sponsor's
or Household Member's Declaration and Certification, and
has verified the accuracy of every answer.
I am fluent in English and
,
5. Interpreter's Mobile Telephone Number (if any)
Interpreter's Signature
(mm/dd/yyyy)Date of Signature7.b.
Interpreter's Signature7.a.
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f.
Postal Code 3.g.
Country
Province
6. Preparer's Email Address (if any)
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
if Other Than the Sponsor or Household Member
Page 6 of 8Form I-864A 10/15/19
I am an attorney or accredited representative and my
representation of the sponsor and household member
in this case
7.b.
extends does not extend beyond
the preparation of this contract.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the
Geographical Confines of the United States, with this
contract.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this contract at the request of the sponsor and
household member. The sponsor and household member then
reviewed this completed contract and informed me that he or
she understands all of the information contained in, and
submitted with, his or her contract, including the Sponsor's or
Household Member's Declaration and Certification, and that
all of this information is complete, true, and correct. I
completed this contract based only on information that the
sponsor and household member provided to me or authorized
me to obtain or use.
Preparer's Signature
I am not an attorney or accredited representative but
have prepared this contract on behalf of the sponsor
and household member and with the sponsor's or
household member's consent.
7.a.
Preparer's Statement
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
if Other Than the Sponsor or Household Member
(continued)
Page 7 of 8Form I-864A 10/15/19
3.d.
5.d.
Part 9. Additional Information
If you need extra space to provide any additional information
within this contract, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this contract or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. A-Number (if any)
3.a. Page Number
3.b. Part Number 3.c. Item Number
5.a.
Page Number 5.b. Part Number 5.c. Item Number
A-
4.d.
4.a. Page Number 4.b. Part Number 4.c. Item Number
6.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
7.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
►
Page 8 of 8Form I-864A 10/15/19
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I-864a Form I-864A, Contract Between Sponsor and Household Member

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Completed 10 July 2020

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