Form I-864A Contract Between Sponsor and Household Member

OMB No. 1615-0075; Expires 09/30/2012

I-864A, Contract Between
Sponsor and Household Member

Department of Homeland Security

U.S. Citizenship and Immigration Services

For Government
Use Only

1. Name

Last Name
First Name

2. Mailing Address

Middle Name

Street Number and Name (include apartment number)
City
Country

3. Place of Residence
(if different from
mailing address)

Draft

Part 1. Information on the Household Member. (You.)

This I-864A relates to
a household member
who:
is the intending
immigrant.

State or Province
Zip/Postal Code

is not the intending
immigrant.

Street Number and Name (include apartment number)
City

State or Province

Country

Zip/Postal Code

4. Telephone Number

(Include area code or country and city codes)

5. Date of Birth

(mm/dd/yyyy)

6. Place of Birth

City

Reviewer

Location
Date (mm/dd/yyyy)

State/Province

Country

7. U.S. Social Security
Number (if any)
8. Relationship to Sponsor (Check either a, b or c.)

a.

I am the intending immigrant and also the sponsor's spouse.

b.

I am the intending immigrant and also a member of the sponsor's household.

c.

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 old)
Parent
Brother or sister
Other dependent (specify)
Form I-864A (09/19/11) Y

9. I am currently:

a.

Employed as a/an

.

Name of Employer #2 (if applicable)

b.

Self-employed as a/an

c.

Retired from

d.

Unemployed since

Draft

Name of Employer # 1 (if applicable)

since

(Company Name)

For Government
Use Only

.
.
.
.

(mm/dd/yyyy)

(mm/dd/yyyy)

10. My current individual annual income is: $__________________________________________.

11. Federal income tax information.

I have filed a Federal tax return for each of the three most recent tax years. I have
attached the required photocopy or transcript of my Federal tax return for only the
most recent tax year.
My total income (adjusted gross income on IRS Form 1040EZ) as reported on my
Federal tax returns for the most recent three years was:
Tax Year
(most recent)

Total Income
$

(2nd most recent) $
(3rd most recent)

$

(Optional) I have attached photocopies or transcripts of my Federal tax returns for my
second and third most recent tax years.
12. My assets (complete only if necessary).

a. Enter the balance of all cash, savings, and checking accounts. $___________________________.
b. Enter the net cash value of real-estate holdings. (Net means
assessed value minus mortgage debt.)

c. Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on line a or b.

$___________________________.
$___________________________.

d. Add together Lines a, b, and c and enter the number here. $___________________________.
Form I-864A (09/19/11) Y Page 2

Part 2. Sponsor's Promise.

For Government
Use Only

Draft

13. I, THE SPONSOR,

(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
immigrant(s) (see Step-by-Step instructions).
Date of Birth

Name

(mm/dd/yyyy)

a.
b.

(Indicate Number)

A-number (if any)

named intending

U.S. Social Security
Number (if any)

c.
d.
e.

14.

(Sponsor's Signature)

(Date--mm/dd/yyyy)

Part 3. Household Member's Promise.
15. I, THE HOUSEHOLD MEMBER,

(Print Name)

in consideration of the sponsor's promise to complete and file an affidavit of support on behalf of the
above
a.

(Number from line 13)

named intending immigrant(s):

Promise to provide any and all financial support necessary to assist the sponsor in maintaining the
sponsored immigrant(s) at or above the minimum income provided for in section 213A(a)(1)(A)
of the Act (not less than 125 percent of the Federal Poverty Guidelines) during the period in
which the affidavit of support is enforceable;

b. 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 immigrant(s), 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 benefit;
c. Certify under penalty under the laws of the United States that all the information provided on this
form is true and correct to the best of my knowledge and belief and 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.
d. 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, 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(s)(1)(A) of the Act (not less than 125 percent of
the Federal poverty line) during the period which the affidavit of support is enforceable.
e.

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.

16.
(Household Member's Signature)

(Date--mm/dd/yyyy)
Form I-864A (09/19/11) Y Page 3