I-864A Contract Between Sponsor and Household Member

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 03/31/2015

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

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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
2.g. Province

Province

Date of Birth

(mm/dd/yyyy)

Place of Birth

2.f.

ZIP Code

6.a. City or Town

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 10/18/13 N

6.c. Country

7.

U.S. Social Security Number (if any)
►

8.

USCIS ELIS Account Number (if any)
►

Page 1 of 8

Part 2. Your (the Household Member's)
Relationship to the Sponsor

Part 4. Your (the Household Member's) Federal
Income Tax Information and Assets

Select Item Number 1.a., 1.b., or 1.c.

1.

1.a.

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

1.b.

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

1.c.

I am not the intending immigrant. I am the sponsor's
household member. 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. I have attached the
required photocopy or transcript of my Federal
income tax return for only the most recent tax year.

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
2.a. Most Recent

Total Income
$

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Spouse

2.b. 2nd Most Recent

$

Son or daughter (at least 18 years of age)

2.c. 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.

My assets (complete only if necessary).

3.a. Enter the balance of all cash, savings, and checking
accounts.

Part 3. Your (the Household Member's)
Employment and Income
I am currently:
1.a.

$

3.b. Enter the net cash value of real-estate holdings. (Net
value means assessed value minus mortgage debt.)
$

Employed as a/an

3.c. Enter the cash value of all stocks, bonds, certificates of

1.a.1.

Name of Employer Number 1 (if applicable)

deposit, and other assets not listed on Item Numbers 3.a.
or 3.b.
$

1.a.2.

Name of Employer Number 2 (if applicable)

3.d. Add together Item Numbers 3.a., 3.b., and 3.c. and enter
the number here.

1.b.

Self employed as a/an

1.c.

Retired from (Company Name)

Since
1.d.

2.

$

(mm/dd/yyyy)

Unemployed since
(mm/dd/yyyy)
My current individual annual income is:
$

Form I-864A 10/18/13 N

Page 2 of 8

9.

Part 5. Sponsor's Promise, Statement, Contact
Information, Certification, and Signature

►
10.

NOTE: Read the information on penalties in the Penalties
section of the Form I-864A Instructions before completing this
part.

Name

,
(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).

11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
11.c. Middle Name

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12.

Date of Birth

13.

A-Number (if any)
► A-

14.

U.S. Social Security Number (if any)

(Indicate Number)

Intending Immigrant Number 1:

(mm/dd/yyyy)

►

15.

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

USCIS ELIS Account Number (if any)
►

Intending Immigrant Number 4:
Name

1.c. Middle Name
2.

Date of Birth

3.

A-Number (if any)
► A-

4.

U.S. Social Security Number (if any)

(mm/dd/yyyy)

►

5.

USCIS ELIS Account Number (if any)
►

Intending Immigrant Number 3:

I, THE SPONSOR,

Name

U.S. Social Security Number (if any)

USCIS ELIS Account Number (if any)

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

16.c. Middle Name
17.

Date of Birth

18.

A-Number (if any)
► A-

19.

U.S. Social Security Number (if any)

►

Intending Immigrant Number 2:

(mm/dd/yyyy)

►

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

20.

USCIS ELIS Account Number (if any)
►

6.c. Middle Name

Name

Intending Immigrant Number 5:

7.

Date of Birth

(mm/dd/yyyy)

8.

A-Number (if any)
► A-

Form I-864A 10/18/13 N

21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)
21.c. Middle Name

Sponsor's Certification

Part 5. Sponsor's Promise, Statement, Contact
Information, Certification, and Signature
(continued)
22.

Date of Birth

23.

A-Number

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, 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. Furthermore, 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.

(mm/dd/yyyy)
► A-

24.

U.S. Social Security Number (if any)

I furthermore authorize release of information contained in this
contract, in supporting documents, and in my USCIS or
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws.

►
25.

USCIS ELIS Account Number (if any)
►

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I certify, under penalty of perjury, that the information in my
contract and any document submitted with my contract were
provided by me and are complete, true, and correct.

Sponsor's Statement

NOTE: Select the box for either Item Number 26.a. or 26.b.
If applicable, select the box for Item Number 27.
26.a.

26.b.

I can read and understand English, and have read and
understand every question and instruction on this
contract, as well as my answer to every question.
The interpreter named in Part 7. has also read to me
every question and instruction on this contract, as
well as my answer to every question, in

I have requested the services of and consented to

,

who

is

is not an attorney or accredited

31.a. Sponsor's Signature

31.b. Date of Signature (mm/dd/yyyy)

,
a language in which I am fluent. I understand every
question and instruction on this contract as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
27.

Sponsor's Signature

Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Certification,
and Signature

NOTE: Read the information on penalties in the Penalties
section of the Form I-864A Instructions before completing this
part.
I, THE HOUSEHOLD MEMBER,

representative, preparing this contract for me.

(Print Name)

Sponsor's Contact Information
28.

Sponsor's Daytime Telephone Number

29.

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.

(Print number of intending immigrants noted in Part 5.
Sponsor's Promise, Statement, Contact Information,
Certification, and Signature.)
A.

Form I-864A 10/18/13 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;

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Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Certification,
and Signature (continued)
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
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;

C.

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;

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(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.

E.

F.

Your (the Household Member's) Statement
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.a.

I can read and understand English, and have read and
understand every question and instruction on this
contract, as well as my answer to every question.

1.b.

The interpreter named in Part 7. has also read to me
every question and instruction on this contract, as
well as my answer to every question, in
,
a language in which I am fluent. I understand every
question and instruction on this contract as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.

DRAFT
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Reporduction
05/04/2015

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.
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).

2.

I have requested the services of and consented to
who

is

,

is not an attorney or accredited

representative, preparing this contract for me.

Your (the Household Member's) Contact
Information

3.

Your (the Household Member's) Daytime Telephone
Number

4.

Your (the Household Member's) Mobile Telephone
Number (if any)

5.

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, original documents, 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. Furthermore, 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.
I furthermore authorize release of information contained in this
contract, in supporting documents, and in my USCIS or the
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws.

Form I-864A 10/18/13 N

Page 5 of 8

Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Certification,
and Signature (continued)

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

I certify, under penalty of perjury, that the information in my
contract and any document submitted with my contract were
provided by me and are complete, true, and correct.

5.

Interpreter's Email Address (if any)

Your (the Household Member's) Signature

Interpreter's Certification

6.a. Your (the Household Member's) Printed Name

I certify that:
I am fluent in English and
which is the same language provided in Part 5., Item
Number 26.b.;

,

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6.b. Your (the Household Member's) Signature

6.c. Date of Signature (mm/dd/yyyy)

Part 7. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

I have read to this sponsor and household member every
question and instruction on this contract, as well as the answer
to every question, in the language provided in Part 5., Item
Number 26.b.; 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, and the
sponsor and household member verified the accuracy of every
answer.

Interpreter's Signature

1.a. Interpreter's Family Name (Last Name)

6.a. Interpreter's Signature

1.b. Interpreter's Given Name (First Name)

6.b. Date of Signature (mm/dd/yyyy)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Provide the following information about the preparer.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Contract, If Other Than the
Household Member

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)

3.e. ZIP Code

Province

3.g. Postal Code

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

3.h. Country

Form I-864A 10/18/13 N

Page 6 of 8

Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Contract, If Other Than the
Household Member (continued)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Province

3.g. Postal Code
3.h. Country

Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this contract on behalf of, at the request
of, and with the express consent of the household member and
sponsor. I completed this contract based only on responses the
household member and sponsor provided to me. After
completing the contract, I reviewed it and all of the household
member's and sponsor's responses with the household member
and sponsor, who agreed with every answer on the contract. If
the household member or sponsor supplied additional
information concerning a question on the contract, I recorded it
on the contract.

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3.e. ZIP Code

Preparer's Signature

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

Preparer's Statement
7.a.

I am not an attorney or accredited representative but
have prepared this contract on behalf of the
household member and sponsor, and with the
household member and sponsor's consent.

7.b.

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.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this contract, you must submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this contract.

Form I-864A 10/18/13 N

Page 7 of 8

5.a. Page Number

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. Include 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.

5.b. Part Number

5.c. Item Number

5.d.

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

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1.c. Middle Name
2.

A-Number (if any)

A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-864A 10/18/13 N

4.c. Item Number

7.a. Your (the Household Member's) Signature

7.b. Date of Signature (mm/dd/yyyy)

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