Affidavit of Support Under Section 213A of the Act

Instructions for 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 03/31/2015

What Is the Purpose of Form I-864A?
Form I-864A, Contract Between Sponsor and Household Member, is an attachment to Form I-864, Affidavit of Support
Under Section 213A of the INA. A separate Form I-864A must be used for each household member whose income
and/or assets are being used by a sponsor to qualify. Each Form I-864A is completed and signed by two individuals: a
sponsor who is completing Form I-864 and a household member who is promising to make his or her income
and/or assets available to the sponsor to help support the sponsored immigrants. The combined signing of this contract
constitutes an agreement that the household member is responsible along with the sponsor for the support of the
individuals named in this contract.

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This contract must be submitted with Form I-864.

Form I-864A may only be used when a sponsor’s income and assets do not meet the income requirements of Form I-864
and the qualifying household member chooses to combine his or her resources with the income and/or assets of a sponsor
to meet the requirements. The obligations of the household member under this contract terminate when the obligations of
the sponsor under the Affidavit of Support terminate.
For additional information, see section 213A of the Immigration and Nationality Act (INA), and part 213a of Title 8 of the
Code of Federal Regulations.
What Is a Sponsor?
A sponsor is:

1. The petitioning relative;

2. A relative with a significant ownership interest in the petitioning entity; or

3. A substitute in the case of a deceased petitioner, or another person accepting joint and several liability with the
sponsor;
AND

4. Someone who completes and files Form I-864 on behalf of an intending immigrant. A sponsor must be an individual
and may not be an enterprise, a business, or any other type of organization.
Who May Be Considered a Household Member for Purposes of Form I-864A?
For purposes of this contract, a household member is:
1. A U.S. citizen, lawful permanent resident, or U.S. national relative who has the same principal residence as the
sponsor and is related to the sponsor as a spouse, adult child, parent, or sibling;
2. A U.S. citizen, lawful permanent resident, or U.S. national relative or other person whom the sponsor has lawfully
claimed as a dependent on the sponsor’s most recent Federal income tax return even if that person does not live at the
same residence as the sponsor; or
3. The intending immigrant, in certain circumstances. (See the How Can the Intending Immigrant Be Considered a
Household Member section of these Instructions.)
How Can the Intending Immigrant Be Considered a Household Member?
Listed below are two ways that the intending immigrant may be considered to be a household member for the purposes of
pooling income with the sponsor to meet the Affidavit of Support requirements:
1. The intending immigrant has the same principal residence as the sponsor and the intending immigrant can establish
that his or her income will continue from the same source, even after acquisition of lawful permanent residence; or
2. The intending immigrant is the sponsor’s spouse and the intending immigrant can show that his or her income will
continue from the same source after acquisition of lawful permanent residence.
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Why Does a Household Member Complete Form I-864A?
A household member completes this contract if the household member’s income and/or assets will be used to demonstrate
the sponsor’s ability to meet the income requirements and to maintain the sponsored immigrant at an annual income at the
level specified in section 213A(f)(l)(E) or 213A(f)(3) of the INA.
If the Intending Immigrant Is a Household Member, Must He or She Complete This Contract?
If you are the intending immigrant and the sponsor is including your income on Form I-864 to meet the eligibility
requirements, you need to complete this contract only if you have accompanying dependents. If you are the intending
immigrant and the sponsor is including only your assets on Form I-864, you do not need to complete this contract, even if
you have accompanying dependents.

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General Instructions

USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you
should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you
do not have Internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that
we mail a form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Signature. Each contract must be properly signed and filed. For all signatures on this contract, USCIS will not accept a
stamped or typewritten name in place of a signature. If you are under 14 years of age, your parent or legal guardian may
sign the contract on your behalf. A legal guardian may also sign for a mentally incompetent person.
If you are under guardianship, your legal guardian may print your name and sign Form I-864 for you. “Legal guardian”
includes any person who is appointed and authorized by law to protect your estate as a result of your incapacity. The
legal guardian must present proof of the appointment as legal guardian of your estate and a copy of an order from the
appointing court or agency specifically permitting the guardian to make your income and assets available for the support
of the sponsored immigrant.
Filing Fee. There is no filing fee to file Form I-864A with USCIS. For information on processing fees when filing with
the Department of State, see www.travel.state.gov.
Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Specific
Instructions section of these Instructions.
Copies. You may submit legible photocopies of documents requested, unless the instructions specifically state that you
must submit an original document. USCIS may request an original document at the time of filing or at any time during
processing of an application, petition, or request. If you submit original documents when not required, the documents
may remain a part of the record, and USCIS will not automatically return them to you.
Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and that
he or she is competent to translate from the foreign language into English.
How To Fill Out Form I-864A
1. Type or print legibly in black ink.
2. If you need extra space to complete any item within this contract, use the space provided in Part 9. Additional
Information or attach a separate sheet of paper; type or print your name and Alien Registration Number (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.

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3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been
married and the question asks “Provide the name of your current spouse”), type or print “N/A,” unless otherwise
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many
children do you have” or “How many times have you departed the United States”), type or print “None,” unless
otherwise directed.

Specific Instructions
This contract is divided into nine parts. The sponsor completes Part 5. Sponsor’s Promise, Statement, Contact
Information, Certification, and Signature of this contract and the household member completes Parts 1., 2., 3., 4., and
6. The information below provides detailed information to help you complete this contract.

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Part 1. Information About You (the Household Member)

Item Numbers l.a. - l.c. Full Name. Provide your full name.

Item Numbers 2.a. - 3. Mailing Address. Provide the address where you receive mail.

Item Numbers 4.a. - 4.h. Physical Address. If you reside in a location different than where you receive mail, provide
the address in the space provided.
Item Number 5. Date of Birth. Provide your date of birth in the mm/dd/yyyy format.

Item Number 6.a. - 6.c. Place of Birth. Provide the city or town, state or province, and country where you were born.
Item Number 7. U.S. Social Security Number (if any). Provide your U.S. Social Security Number if you have one.
Item Number 8. USCIS ELIS Account Number (if any). If you have previously filed an application, petition, or
request using the USCIS Electronic Immigration System (USCIS ELIS), provide the USCIS ELIS Account Number you
were issued by the system. The USCIS ELIS Account Number is not the same as an A-Number. If you were issued a
USCIS ELIS Account Number, enter it in the space provided.
Part 2. Your (the Household Member’s) Relationship to the Sponsor

Item Numbers 1.a. - 1.c. Select the item which best reflects your relationship to the sponsor.

If you select Item Number 1.a. (married to the sponsor), you do not have to reside with the sponsor, but you must provide
proof that your income will continue from the same source after immigration.
If you select Item Number 1.b. (not married to the sponsor), you must provide proof that you currently have the same
principal residence as the sponsor and that your income will continue from the same source after immigration.
If you are the household member completing this contract, but are not the intending immigrant, select Item Number 1.c.,
and select the box below that describes your relationship to the sponsor. If you select “Other dependent,” you must be
listed as a dependent on the sponsor’s most recent Federal income tax return. You do not have to provide proof that you
have the same principal residence as the sponsor. If you select any other relative except for spouse, you must provide
proof of the relationship and that you have the same principal residence as the sponsor.
Part 3. Your (the Household Member’s) Employment and Income
Item Number 1.a. - 1.d. Your (the Household Member’s) Employment.
Select all boxes that apply to you. A sponsor may not rely on a household member’s income from illegal activities, such
as proceeds from illegal gambling or drug sales, to meet the income requirements, even if the household member paid
taxes on that income.
Item Number 2. Current Individual Annual Income. Enter your current individual earned or retirement annual income
that you are using to meet the requirements of this contract and indicate the total on this line.

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You may include evidence supporting your claim about your expected income for the current year if you believe that
submitting this evidence will help you establish ability to maintain sufficient income. You are not required to submit
this evidence, however, unless specifically instructed to do so by a Government official. For example, you may include
a recent letter from your employer, showing your employer’s address and telephone number, and indicating your annual
salary. You may also provide pay stubs showing your income for the previous six months. If your claimed income
includes alimony, child support, dividend or interest income, or income from any other source, you may also include
evidence of ability to maintain that income.
Part 4. Your (the Household Member’s) Federal Income Tax Information and Assets
You must provide either an Internal Revenue Service (IRS) transcript or a photocopy from your own records of your
Federal individual income tax return for the most recent tax year. If you believe additional returns may help you to
establish your ability to maintain sufficient income, you may submit transcripts or photocopies of your Federal individual
income tax returns for the three most recent years.

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You are not required to have the IRS certify the transcript or photocopy unless specifically instructed to do so by a
Government official; a plain transcript or photocopy is acceptable. Telefile tax records are not acceptable proof of filing.
Do not submit copies of your state income tax returns. Do not submit any tax returns that you filed with any foreign
government unless you are claiming that you were not required to file a Federal income tax return with the United States
Government and you wish to rely on the foreign return solely to establish the amount of your income that was not subject
to tax in the United States.
If you provide a photocopy of your tax returns, you must include a copy of each and every FormW-2 and Form 1099 that
relates to your returns. Do not include copies of these Forms if you provide an IRS transcript of your returns rather than a
photocopy unless you filed a joint Federal income tax return with your spouse.
If you selected Item Number 1.b. in Part 3, that you are self-employed, you should have completed one of the following
forms with your Federal income tax return: Schedule C (Profit or Loss from Business), Schedule D (Capital Gains),
Schedule E (Supplemental Income or Loss), or Schedule F (Profit or Loss from Farming). You must include each and
every Form 1040 Schedule, if any, that you filed with your Federal income tax return.
If you were required to file a Federal income tax return during any of the previous three tax years but did not do so, you
must file any and all late returns with IRS and attach an IRS-generated tax return transcript documenting your late filing
before submitting Form I-864A. If you were not required to file a Federal income tax return under U.S. tax law because
your income was too low, attach a typed or printed explanation.
If you were not required to file a Federal income tax return under U.S. tax law for any other reason, attach a typed or
printed explanation including evidence of the exemption and how you qualified for it. Residence outside of the United
States does not exempt U.S. citizens or lawful permanent residents from filing a U.S. Federal income tax return. See
Filing Requirements in the IRS Form 1040 Filing Instructions to determine whether you were required to file.
For purposes of this contract, the line for Total Income on IRS Forms 1040 and 1040A will be considered when
determining income. For persons filing IRS Form 1040 EZ, the line for Adjusted Gross Income will be considered.
Obtaining Tax Transcripts. You may use IRS Form 4506-T to request tax transcripts from the IRS. Complete IRS
Form 4506-T with the ending date for each of your three most recent tax years listed on line 9. Follow all instructions for
completing and filing Form 4506-T with the IRS.
Item Number 1. Select the box if you filed a Federal income tax return for each of the three most recent tax years and
have attached the required photocopy or transcript of your Federal income tax return for only the most recent year.
Item Numbers 2.a. - 2.c. Most Recent Tax Year Total Income. Indicate the most recent tax year and your Total Income
for that most recent tax year. If that amount was zero, enter “zero” or “N/A” for non-applicable. If applicable, select the
Optional box indicating that you have attached photocopies or transcripts of your Federal income tax returns for your
second and third most recent tax years.
Item Number 3.a. - 3.d. Assets. Complete this item only if the sponsor is using the value of your assets to help meet the
requirements of the affidavit of support. If you are using only your income to help the sponsor meet the requirements, do
not complete this item.
If you are the intending immigrant and have no accompanying dependents, then do not list your assets on this contract.
Instead, you must list your assets in Part 7., Item Numbers 6. - 10. of Form I-864.

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Only assets that can be converted into cash within one year and without considerable hardship or financial loss to the
owner may be included. The owner of the asset must include a description of the asset, proof of ownership, and the basis
for the owner’s claim of its net cash value.
You may include the net value of your home as an asset. The net value of the home is the appraised value of the home,
minus the sum of any and all loans secured by a mortgage, trust deed, or other lien on the home.
If you wish to include the net value of your home, you must include documentation demonstrating that you own it, a
recent appraisal by a licensed appraiser, and evidence of the amount of any and all loans secured by a mortgage, trust
deed, or other lien on the home. You may not include the net value of an automobile unless you show that you have more
than one automobile, and at least one automobile is not included as an asset.
Part 5. Sponsor’s Promise, Statement, Contact Information, Certification, and Signature

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Item Numbers 1.a. - 31.b. If the sponsor you are promising to make your income available to is sponsoring the principal
intending immigrant (the sponsor should have “Yes” as his or her answer to Part 3., Item Number 1. of his or her Form
I-864), you should list the intending immigrant in Part 5., Item Number 1.a. - 1.c. and then list any spouse and any and
all children that are listed in the sponsor’s Form I-864 in the spaces that follow in Part 5. of Form I-864A.
If the sponsor you are promising to make your income available to is not sponsoring the intending immigrant (this should
be true only in cases with two joint sponsors, with “No” selected on Part 3., Item Number 1. of his or her Form I-864),
in Part 5., Item Number 1.a. - 1.c., list any spouse and any and children that appear on the sponsor’s Form I-864, in the
spaces that follow in Part 5. of Form I-864A.
Select the appropriate box to indicate that you either read this contract yourself or someone interpreted this contract for
you from English to a language in which you are fluent. If applicable, select the box to indicate if someone prepared
this contract for you. Further, you must sign and date your contract and provide your daytime telephone number, mobile
telephone number (if any), and email address (if any). Every contract MUST contain the signature of the sponsor (or
parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.
Part 6. Your (the Household Member’s) Promise, Statement, Contact Information, Certification, and Signature
Item Numbers 1.a. - 6.c. Read the household member’s promise carefully, type or print your name in the spaces
provided in Part 6. then sign and date the contract. If you do not print your name in the Signature section and sign
and date the contract, the intending immigrant cannot be issued a visa or be granted adjustment of status based
upon the income and/or assets listed on this contract.
If you are under guardianship, your legal guardian may type or print your name on Form I-864A for you to sign . See
General Instructions for definition of “legal guardian.”
Select the appropriate box to indicate that you either read this contract yourself or someone interpreted this contract for
you from English to a language in which you are fluent. If applicable, select the box to indicate if someone prepared
this contract for you. Further, you must sign and date your contract and provide your daytime telephone number, mobile
telephone number (if any), and email address (if any). Every contract MUST contain the signature of the requestor (or
parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.
Part 7. Interpreter’s Contact Information, Certification, and Signature
Item Numbers 1.a. - 6.b. If you used anyone as an interpreter to read the Instructions and questions on this contract to
you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and
address of his or her business or organization (if any), his or her daytime telephone number, and his or her email address
(if any). The interpreter must sign and date the contract.

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Part 8. Contact Information, Statement, Certification, and Signature of the Person Preparing this Contract, If
Other Than the Household Member
Item Numbers 1.a. - 8.b. This section must contain the signature of the person who completed your contract, if other
than you, the household member. If the same individual acted as your interpreter and your preparer, that person should
complete both Part 7. and Part 8. If the person who completed this contract is associated with a business or organization,
that person should complete the business or organization name and address information. Anyone who helped you prepare
this contract MUST sign and date the contract. A stamped or typewritten name in place of a signature is not acceptable.
If the person who helped you prepare your contract is an attorney or accredited representative, he or she must also submit
a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with your
contract, if his or her representation extends beyond preparation of this contract.
Part 9. Additional Information

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Item Numbers 1.a. - 7.b. If you need extra space to provide any additional information within this contract, use the
space provided in Part 9. Additional Information. If you need more space than what is provided in Part 9., you may
make copies of Part 9. to complete and file with your 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.
We recommend that you print or save a copy of your completed contract to review in the future and for your
records.

What Evidence Should You Submit?

You must submit all evidence requested in these Instructions with your contract. If you fail to submit required evidence,
USCIS may reject or deny your contract for failure to submit requested evidence or supporting documents in accordance
with 8 CFR 103.2(b)(1) and these Instructions.

What Is The Filing Fee

There is no filing fee to file form I-864A. For information on processing fees when filing with the Department of State,
see www.travel.state.gov.

Where to File
This contract MUST be filed with Form I-864.
For additional information, please see the USCIS Web site at www.uscis.gov/I-864 or call the USCIS National Customer
Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833. For information on filing
with the Department of State, see www.travel.state.gov.

Address Change
If you have changed your address, you must inform USCIS or DOS of your new address within 30 days of the change.
For reporting a change of address to USCIS, you must complete and file Form I-865, Sponsor’s Change of Address. For
information on filing Form I-865, go to the USCIS Web site at www.uscis.gov/I-865 or contact the National Customer
Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
NOTE: Do not complete Form I-865 at the same time that you complete Form I-864A. You should complete and
submit Form I-865 to USCIS only when the address you indicated on the original Form I-864A has changed.

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This requirement does not relieve a lawful permanent resident sponsor from filing a change of address within 10 days of
the change. For information on filing a change of address, go the the USCIS Web site at www.uscis.gov/addresschange
or contact the National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call:
1-800-767-1833. For information on reporting a change of address to the Department of State, see www.travel.state.gov.
NOTE: Do not submit a change of address request to USCIS Lockbox facilities because these facilities do not process
change of address requests.

Processing Information
Initial Processing. Once USCIS or the Department of State accepts your contract we will check it for completeness. If
you do not completely fill out this contract, you will not establish a basis for your eligibility and USCIS or the Department
of State may reject or deny your contract.

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Requests for More Information. We may request that you provide more information or evidence to support your
contract. We may also request that you provide the originals of any copies you submit. USCIS will return any requested
originals when they are no longer needed.
Requests for Interview. We may request that you appear at a USCIS office for an interview based on your contract.
At the time of any interview or other appearance at a USCIS office, we may require that you provide your fingerprints,
photograph, and/or signature to verify your identity and/or update background and security checks.
Decision. The decision on Form I-864A involves a determination of whether you have established eligibility for the
immigration benefit you are seeking. USCIS will notify you of the decision in writing.

USCIS Forms and Information

To ensure you are using the latest version of this contract, visit the USCIS Web site at www.uscis.gov where you can
obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order
USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling
the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call:
1-800-767-1833.
Instead of waiting in line for assistance at your local USCIS office, you can now schedule an appointment through our
online system, InfoPass, at infopass.uscis.gov. Use the InfoPass appointment scheduler and follow the screen prompts
to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen. If filing with
the Department of State, see www.travel.state.gov.

Penalties
If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-864A, we
will deny your Form I-864A and may deny any other immigration benefit. In addition, you will face severe penalties
provided by law and may be subject to criminal prosecution.
The Government may pursue verification of any information provided on or in support of this contract, including
employment, income, or assets with the employer, financial or other institutions, the IRS, or the Social Security
Administration. If you include in this contract any information that you know to be false, you may be liable for criminal
prosecution under the laws of the United States.
If you fail to give notice of your change of address, as required by 8 U.S.C. 1183a(d) and 8 CFR 213a.3, you may be
liable for the civil penalty established by 8 U.S.C. 1183a(d)(2). The amount of the civil penalty will depend on whether
you failed to give this notice because you were aware that the immigrants you sponsored had received Federal, state, or
local means-tested public benefits.

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If the failure to report your change of address occurs with knowledge that the sponsored immigrant received means-tested
public benefits (other than benefits described in section 401(b), 403(c)(2), or 4ll(b) of the Personal Responsibility and
Work Opportunity Reconciliation Act of 1996, which are summarized in the contract in Part 8. of Form I-864,) such
failure may result in a fine of not less than $2,000 or more than $5,000. Otherwise, the failure to report your change of
address may result in a fine not less than $250 or more than $2,000.

USCIS Privacy Act Statement
AUTHORITIES: The information requested on this contract, and the associated evidence, is contained in 8 U.S.C.
1182a(4), 1183a, 1184(a), and 1258.

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PURPOSE: The information will be used principally by USCIS, a Consular Officer, or an immigration judge to whom it
is furnished, to accompany a sponsor’s Form I-864, Affidavit of Support Under Section 213A of the INA, which supports
an alien’s application for benefits under the INA, specifically the assertion that he or she has adequate means of financial
support and will not become a public charge.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and
any requested evidence, may result in denial of the application for an immigrant visa or adjustment of status, and delay a
final decision in your case or result in denial of your contract.
ROUTINE USES: DHS may share the information you provide on this contract with other Federal, state, local, and
foreign government agencies and authorized organizations. Social Security numbers may be verified with the Social
Security Administration. DHS follows approved routine uses described in the associated published system of records
notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001 - Alien File, Index, and National File
Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS may also share the information, as
appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection
of information, unless it displays a currently valid OMB control number. The public reporting burden for this collection
of information is estimated at 1 hour and 45 minutes per contract, including the time for reviewing instructions, gathering
the required documentation and information, completing the contract, preparing statements, attaching necessary
documentation, and submitting the contract. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services,
Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 205292140; OMB No. 1615-0075. Do not mail your completed Form I-864A to this address.

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Checklist
The following items must be submitted with Form I-864A:
For ALL sponsors:

□□ A copy of your individual Federal income tax return, including W-2s for the most recent tax year, or a statement

and/or evidence describing why you were not required to file. Also include a copy of each and every Form 1099,
Schedule, and any other evidence of reported income. You may submit this information for the most recent three tax
years, pay stubs from the most recent six months, and/or a letter from your employer if you believe any of these items
will help you qualify.

For SOME sponsors:

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If your legal guardian is signing this Form I-864A for you, the legal guardian must present:

□□ Proof of the appointment as legal guardian of your estate; and
□□ A copy of an order from the appointing court or agency specifically permitting the legal guardian to make your
income and assets available for the support of the sponsored immigrant.

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