Table of Changes I-864A Form

Form I-864A, Form TOC

Contract Between Sponsor and Household Member

OMB Number: 1615-0075

Date: 5/04/2015

Reason for Revision: Updates to format and standard language, and edits provided by subject matter experts.

Location	Current Text	Proposed Text
Page 1, Part 1. Information on the Household Member. (You)	Name Last Name First Name Middle Name Mailing Address Street Number and Name (include apartment number) City State or Province Zip/Postal Code Country Place of Residence (if different from mailing address) Street Number and Name (include apartment number) City State or Province Zip/Postal Code Country Telephone Number (Include area code or country and city codes) Date of Birth (mm/dd/yyyy) Place of Birth City State/Province Country U.S. Social Security Number (if any)	[Page 1] START HERE - Type or print in black ink Part 1. Information About You (the Household Member) Full Name. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name (if any) Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. [Fillable Field] 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country 3. Is your current mailing address the same as your physical address? If you answered “No” to Item Number 3., provide your physical address. Physical Address 4.a. Street Number and Name 4.b. Apt. Ste. Flr. [Fillable Field] 4.c. City or Town 4.d. State 4.e. ZIP Code 4.f. Province 4.g. Postal Code 4.h. Country [Deleted] Other Information 5. Date of Birth (mm/dd/yyyy) Place of Birth 6.a. City or Town 6.b. State or Province 6.c. Country 7. U.S. Social Security Number (if any) 8. USCIS ELIS Account Number (if any)
Page 1, Part 1. Information on the Household Member. (You)	Relationship to Sponsor(check either a, b or 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. I am not the intending immigrant. I am the sponsor’s household member. I am related the sponsor as his/her. Spouse Son or daughter (at least 18 years old) Parent Brother or sister Other dependent (specify)	[Page 1] Part 2. Your (the Household Member’s) Relationship to the Sponsor Select Item Number 1.a., 1.b., or 1.c. 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 the sponsor as his/her. Spouse Son or daughter (at least 18 years of age) Parent Brother or sister Other dependent (Specify)
Page 1, Part 1. Information on the Household Member. (You)	I am currently: Employed as a/an [Fillable Field] Name of Employer No. 1 (if applicable) Name of Employer No. 2 (if applicable) Self-employed as a/an [Fillable Field] Retired from [Fillable Field] (Company Name) since [Fillable Field] (mm/dd/yyyy) Unemployed since [Fillable Field] (mm/dd/yyyy) My current individual annual income is: [Fillable Field]	[Page 2] Part 3. Your (the Household Member’s) Employment and Income I am currently: 1.a. Employed as a/an [Fillable Field] 1.a.1. Name of Employer Number 1 (if applicable) 1.a.2. Name of Employer Number 2 (if applicable) 1.b. Self employed as a/an [Fillable Field] 1.c. Retired from [Fillable Field] (Company Name) since [Fillable Field] (mm/dd/yyyy) 1.d. Unemployed since [Fillable Field] (mm/dd/yyyy) 2. My current individual annual income is: [Fillable Field]
Page 1, Part 1. Information on the Household Member. (You)	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 Total Income [Fillable Field] (most recent) [Fillable Field] [Fillable Field] (2nd most recent) [Fillable Field] [Fillable Field] (3rd most recent) [Fillable Field] (Optional) I have attached photocopies or transcripts of my Federal tax returns for my second and third most recent tax years. My assets (complete only if necessary). Enter the balance of all cash, savings, and checking accounts. Enter the net cash value of real-estate holdings. (Net means assessed value minus mortgage debt.) Enter the cash value of all stocks, bonds, certificates of deposit, and other assets not listed on line a or b. Add together Lines a, b, and c and enter the number here.	[Page 2] Part 4. Your (the Household Member’s) Federal Income Tax Information and Assets 1. 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 Total Income 2.a. Most Recent 2.b. 2nd Most Recent 2.c. 3rd Most Recent (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. 3.b. Enter the net cash value of real-estate holdings. (Net value means assessed value minus mortgage debt.) 3c. Enter the cash value of all stocks, bonds, certificates of deposit, and other assets not listed in Item Numbers 3.a. and 3.b. 3.d. Add together Item Numbers 3.a., 3.b., and 3.c. and enter the number here.
Page 2, Part 2. Sponsor’s Promise.	I, THE SPONSOR, [Fillable Field] (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 [Fillable Field] named intending (Indicate Number) immigrant(s) (see Step-by-Step instructions). Name Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) Name Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) Name Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) Name Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) Name Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) 2. (Sponsor’s Signature) (Date--mm/dd/yyyy)	[Page 2] Part 5. Sponsor’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 SPONSOR, [Fillable Field] (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). [Fillable Field] (Indicate Number) Intending Immigrant Number 1: Name 1.a. Family Name 1.b. Given Name 1.c. Middle Name 2. Date of Birth (mm/dd/yyyy) 3. A-Number (if any) 4. U.S. Social Security Number (if any) 5. USCIS ELIS Account Number (if any) Intending Immigrant Number 2: Name 6.a. Family Name 6.b. Given Name 6.c. Middle Name 7. Date of Birth (mm/dd/yyyy) 8. A-Number (if any) 9. U.S. Social Security Number (if any) 10. USCIS ELIS Account Number (if any) Intending Immigrant Number 3: Name 11.a. Family Name 11.b. Given Name 11.c. Middle Name 12. Date of Birth (mm/dd/yyyy) 13. A-Number (if any) 14. U.S. Social Security Number (if any) 15. USCIS ELIS Account Number (if any) Intending Immigrant Number 4: Name 16.a. Family Name 16.b. Given Name 16.c. Middle Name 17. Date of Birth (mm/dd/yyyy) 18. A-Number (if any) 19. U.S. Social Security Number (if any) 20. USCIS ELIS Account Number (if any) Intending Immigrant Number 5: Name 21.a. Family Name 21.b. Given Name 21.c. Middle Name 22. Date of Birth (mm/dd/yyyy) 23. A-Number (if any) 24. U.S. Social Security Number (if any) 25. USCIS ELIS Account Number (if any) 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. 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. 26.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 [Fillable Field], 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. I have requested the services of and consented to [Fillable Field], who is/is not an attorney or accredited representative, preparing this contract for me. 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) Sponsor’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 Department of State record to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. 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 Signature 31.a. Sponsor’s Signature 31.b. Date of Signature (mm/dd/yyyy)
Page 3, 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 [Fillable Field] named intending immigrant(s): (Number from line 13) 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)	[Page 4] 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, [Fillable Field] (Print Name) in consideration of the sponsor's promise to complete and file an affidavit of support on behalf of the above named intending immigrants. [Fillable Field] (Print number of intending immigrants noted in Part 5. Sponsor’s Promise, Statement, Contact Information, Certification, and Signature) A. 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; 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 Guidelines) during the period which the affidavit of support is enforceable. E. 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. F. 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). 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 [Fillable Field], 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. 2. I have contracted the services of and consented to [Fillable Field], 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. 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. Your (the Household Member’s) Signature 6.a. Your (the Household Member’s) Printed Name 6.b. Your (the Household Member’s) Signature 6.c. Date of Signature (mm/dd/yyyy)
New		[Page 5] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter’s Full Name 1.a. Interpreter’s Family Name (Last Name) 1.b. Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. [Fillable Field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter’s Contact Information 4. Interpreter’s Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 5., Item Number 26.b.; 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 6.a. Interpreter’s Signature 6.b. Date of Signature (mm/dd/yyyy)
New		[Page 6] Part 8. Contact Information, Statement, Certification, and Signature of the Person Preparing this Contract, If Other Than the Household Member Provide the following information about the preparer. Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. [Fillable Field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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. 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. Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)
New		[Page 8] 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. 1.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable Field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable Field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable Field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable Field] 7.a. Your (the Household Member’s) Signature 7.b. Date of Signature (mm/dd/yyyy)

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