Form I-864A Contract Between Sponsor and Household Member

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 07/31/2017

For Government Use Only
This Form I-864A relates to a household member who:
IS the intending
immigrant

IS NOT the
intending
immigrant

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 or
G-28I is attached.

Reviewed By:
Location:

Date (mm/dd/yyyy):

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

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► START HERE - Type or print in black ink.

Part 1. Information About You (the Household
Member)
Full Name

Physical Address

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 07/02/15 N

6.c. Country

7.

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

8.

USCIS Online Account Number (if any)
►

Page 1 of 8

NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
tax year.

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 to the sponsor as
his/her:

1.b.

(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
third most recent tax years.

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

$

Spouse

2.b. 2nd Most Recent

$

Son or Daughter (at least 18 years of age)

2.c. 3rd Most Recent

$

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Parent

My assets (complete only if necessary).

Brother or Sister

Other Dependent (Specify)

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.)

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

Employed as a/an

2.

Name of Employer Number 1

3.

Name of Employer Number 2 (if applicable)

$

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

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

4.

Self employed as a/an

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

5.

Retired from (Company Name)

I, THE SPONSOR,

Since (mm/dd/yyyy)

6.

Unemployed since (mm/dd/yyyy)

7.

My current individual annual income is:
$

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

,

(Print Name)

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.

(Indicate Number)

1.a. Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No

Form I-864A 07/02/15 N

Page 2 of 8

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

13.

Alien Registration Number (A-Number, if any)
► A-

14.

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

Intending Immigrant Number 1
Name

15.

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

Intending Immigrant Number 4
Name

1.c. Middle Name
2.

Date of Birth (mm/dd/yyyy)

3.

Alien Registration Number (A-Number, if any)
► A-

4.

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

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

5.

USCIS Online Account Number (if any)
►

USCIS Online Account Number (if any)
►

16.c. Middle Name
17.

Date of Birth (mm/dd/yyyy)

18.

Alien Registration Number (A-Number, if any)
► A-

19.

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

Intending Immigrant Number 2
Name

20.

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

►

Intending Immigrant Number 5

Name

6.c. Middle Name
7.

Date of Birth (mm/dd/yyyy)

8.

Alien Registration Number (A-Number, if any)
► A-

9.

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

10.

USCIS Online Account Number (if any)

USCIS Online Account Number (if any)
►

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

21.c. Middle Name
22.

Date of Birth (mm/dd/yyyy)

23.

Alien Registration Number (A-Number, if any)
► A-

24.

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

Intending Immigrant Number 3
Name
11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
11.c. Middle Name
12.

Date of Birth (mm/dd/yyyy)

Form I-864A 07/02/15 N

25.

USCIS Online 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 I have read
and understand every question and instruction on this
contract and my answer to every question.

Page 3 of 8

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

26.b.

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

The interpreter named in Part 7. read to me every
question and instruction on this contract and my
answer to every question in

I, THE HOUSEHOLD MEMBER,
,

a language in which I am fluent, and I understood
everything.
27.

,
(Print Name)

At my request, the preparer named in Part 8.,
,
prepared this contract for me based only upon
information I provided or authorized.

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Sponsor's Contact Information
28.

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

Sponsor's Daytime Telephone Number

29.

Sponsor's Mobile Telephone Number (if any)

30.

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.

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.

Sponsor's Signature
31.a. Sponsor's Signature

31.b. Date of Signature (mm/dd/yyyy)
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.
Form I-864A 07/02/15 N

(Print number of intending immigrants noted in Part 5.
Sponsor's Promise, Statement, Contact Information,
Declaration, 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 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;

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, 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.

Page 4 of 8

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

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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 I have read
and understand every question and instruction on this
contract and my answer to every question.

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

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

,

At my request, the preparer named in Part 8.,

Your (the Household Member's) Contact
Information

Your (the Household Member's) Daytime Telephone
Number

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

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

,

prepared this contract for me based only upon
information I provided or authorized.

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.

Your (the Household Member's) Signature

a language in which I am fluent, and I understood
everything.

3.

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.

Your (the Household Member's) Statement

2.

Your (the Household Member's) Declaration and
Certification

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.

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

Provide the following information about the interpreter.

4.

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

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)
5.

Your (the Household Member's) Email Address (if any)
1.b. Interpreter's Given Name (First Name)

2.

Form I-864A 07/02/15 N

Interpreter's Business or Organization Name (if any)

Page 5 of 8

Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
if Other Than the Sponsor or Household Member
Provide the following information about the preparer.

Preparer's Full Name
Ste.

Flr.

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

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

3.e. ZIP Code

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

Province
2.

Preparer's Business or Organization Name (if any)

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3.g. Postal Code
3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

Preparer's Mailing Address

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code

Interpreter's Certification

3.h. Country

I certify, under penalty of perjury, that:

I am fluent in English and
,
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.

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Signature
7.a. Interpreter's Signature

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

Form I-864A 07/02/15 N

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Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
if Other Than the Sponsor or Household Member
(continued)
Preparer's Statement
7.a.

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.b.

I am an attorney or accredited representative and my
representation of the sponsor and household member
in this case
extends
does not extend beyond
the preparation of this contract.

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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.

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
8.a. Preparer's Signature

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

Form I-864A 07/02/15 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. 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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

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A-Number (if any)

► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

Form I-864A 07/02/15 N

4.c. Item Number

7.a. Page Number

7.d.

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