I-864A Form TOC

TABLE OF CHANGES – FORM

Form I-864A, Contract Between Sponsor and Household Member

OMB Number: 1615-0075

6/19/2017

Reason for Revision: Update to standard language.

Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or accredited representative (if any).	[page 1] [new] START HERE - Type or print in black ink.	[page 1] To be completed by an attorney or accredited representative (if any). [ ] Select this box if Form G-28 or G-28I is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink.
Page 1, Part 1. Information About You (the Household Member)	[page 1] 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 Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 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? Yes/No 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. 4.c. City or Town 4.d. State 4.e. ZIP Code 4.f. Province 4.g. Postal Code 4.h. Country 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] [no change] 8. USCIS Online Account Number (if any)
Page 2, Part 2. Your (the Household Member's) Relationship to the Sponsor	[page 2] 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: [ ] Spouse [ ] Son or daughter (at least 18 years of age) [ ] Parent [ ] Brother or sister [ ] Other dependent (Specify)	[page 2] Part 2. Your (the Household Member's) Relationship to the Sponsor Select Item Number 1.a., 1.b., or 1.c. [no change]
Page 2, Part 3. Your (the Household Member's) Employment and Income	[page 2] Part 3. Your (the Household Member's) Employment and Income I am currently: 1.a. [ ] Employed as a/an 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 1.c. [ ] Retired from (Company Name) Since (mm/dd/yyyy) 1.d. [ ] Unemployed since (mm/dd/yyyy) 2. My current individual annual income is: $	[page 2] 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) 4. [ ] Self employed as a/an 5. [ ] Retired from (Company Name) Since (mm/dd/yyyy) 6. [ ] Unemployed since (mm/dd/yyyy) 7. My current individual annual income is: $
Page 2, Part 4. Your (the Household Member's) Federal Income Tax Information and Assets	[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.) $ 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. $	[page 2] Part 4. Your (the Household Member's) Federal Income Tax Information and Assets 1.a. Have you filed a Federal income tax return for each of the three most recent tax years? Yes/No NOTE: You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year. 1.b. (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third most recent tax years. [no change] [ ] (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third most recent tax years. [no change]
Pages 3-4, Part 5. Sponsor's Promise, Statement, Contact Information, Certification, and Signature	[page 3] 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 box], (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 box] (Indicate Number) Intending Immigrant Number 1: Name 1.a. Family Name (Last Name) 1.b. Given Name (First 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 (Last Name) 6.b. Given Name (First 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 (Last Name) 11.b. Given Name (First 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 (Last Name) 16.b. Given Name (First 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 (Last Name) 21.b. Given Name (First Name) 21.c. Middle Name [page 4] 22. Date of Birth (mm/dd/yyyy) 23. A-Number 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 2] Part 5. Sponsor's Promise, Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-864A Instructions before completing this part. I, THE SPONSOR, [fillable box], (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. [fillable box] (Indicate Number) [page 3] Intending Immigrant Number 1 [no change] 2. Date of Birth (mm/dd/yyyy) 3. Alien Registration Number (A-Number, if any) 4. U.S. Social Security Number (if any) 5. USCIS Online Account Number (if any) [no change] 8. Alien Registration Number (A-Number, if any) 9. U.S. Social Security Number (if any) 10. USCIS Online Account Number (if any) [no change] 13. Alien Registration Number (A-Number, if any) [no change] 15. USCIS Online Account Number (if any) Intending Immigrant Number 4 [no change] 18. Alien Registration Number (A-Number, if any) [no change] 20. USCIS Online Account Number (if any) [no change] [no change] 23. Alien Registration Number (A-Number) (if any) [no change] 25. USCIS Online Account Number (if any) [no change] 26.a. [ ] I can read and understand English, I and have read and understand every question and instruction on this contract and my answer to every question. [page 4] 26.b. [ ] The interpreter named in Part 7. read to me every question and instruction on this contract and my answer to every question in [fillable field], a language in which I am fluent, and I understood everything. 27. [ ] At my request, the preparer named in Part 8., [Fillable Filed], prepared this contract for me based only upon information I provided or authorized. [no change] 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. [no change] 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.
Pages 4-6, Part 6. Your (the Household Member's) Promise, Statement, Contact Information, Certification, and Signature	[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 box], (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 box] (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; [page 5] 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. 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 box] , 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 requested the services of and consented to [fillable box], 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. [page 6] 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)	[page 4] Part 6. Your (the Household Member's) Promise, Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-864A Instructions before completing this part. I, THE HOUSEHOLD MEMBER, [fillable box], (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 box] (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; [no change] 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 5] [no change] 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 [Fillable Field], a language in which I am fluent, and I understood everything. 2. [ ] At my request, the preparer named in Part 8., [Fillable Filed], prepared this contract for me based only upon information I provided or authorized. [no change] Your (the Household Member's) Declaration and Certification 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. 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. [no change] 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.
Page 6, Part 7. Interpreter's Contact Information, Certification, and Signature	[page 6] 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. 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 box], 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)	[page 5] [no change] [page 6] [no change] 5. Interpreter’s Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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. Interpreter's Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)
Pages 6-7, Part 8. Contact Information, Statement, Certification, and Signature of the Person Preparing this Contract, If Other Than the Household Member	[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) [page 7] Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 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)	[page 6] Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Contract, if Other Than the Sponsor or Household Member [no change] [no change] 5. Preparer’s Mobile Telephone Number (if any) [no change] [page 7] 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. [no change] 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. [no change]
Page 8, Part 9. Additional Information	[page 8] Part 9. Additional Information If you need extra space to provide any additional information within this affidavit, 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 affidavit 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. Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [fillable lines] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [fillable lines] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [fillable lines] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [fillable lines]	[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. 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. [deleted] [no change] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [fillable lines]

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