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 03/31/2020

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 executed by the sponsor’s spouse whose income and/
or assets are being used by a sponsor to meet the income requirements of section 213A of the Immigration and Nationality
Act (INA), if the spouse is not the intending immigrant. Each Form I-864A is executed by two individuals: the sponsor
who is executing Form I-864 and a household member (the sponsor’s spouse or the intending immigrant in certain
circumstances) who is promising to make his or her income and/or assets available to the sponsor to help support the
sponsored immigrants. The combined execution 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 section 213A
of the INA and the qualifying household member chooses to combine his or her income and/or assets with the income
and/or assets of a sponsor to meet the income requirements. The obligations of the household member under this contract
terminate when the obligations of the sponsor under the Form I-864 terminate, unless the sponsor’s obligation terminated
because of the sponsor’s death. A household member’s obligation under this contract also terminates when the household
member dies.
For additional information, see section 213A of the INA and Title 8 of the Code of Federal Regulations Part 213a.
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. An individual who executed 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, one or more of the following individuals may execute the Form I-864A as a household
member if at least 18 years of age:
1. The sponsor’s spouse; or
2. The intending immigrant, if the sponsor seeks to rely on an intending immigrant’s continuing income to establish the
sponsor’s ability to support the intending immigrant’s spouse or children.
How Can the Intending Immigrant Be Considered a Household Member for Purposes of Form I-864A?
Listed below are the only two ways that the intending immigrant may be considered a household member for the purposes
of combining income with the sponsor to meet the income requirements in section 213A of the INA:

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1. The intending immigrant has the same principal residence as the sponsor and the intending immigrant can establish
that his or her income is accrued or earned from employment in a lawful enterprise or some other lawful source and
employment that is authorized pursuant to 8 CFR 274a.12, and will continue to be derived from a lawful source after
acquisition of lawful permanent resident status; or
2. The intending immigrant is the sponsor’s spouse and the intending immigrant can show that his or her income is
accrued or earned from employment in a lawful enterprise or some other lawful source and employment that is
authorized pursuant to 8 CFR 274a.12, and will continue to be derived from a lawful source after acquisition of lawful
permanent resident status.
The intending immigrant only executes Form I-864A when his or her income and/or assets are being combined with the
sponsor’s income and assets to sponsor the intending immigrant’s spouse or children.

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Why Does a Household Member Execute Form I-864A?

A household member executes 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 the means to maintain the sponsored immigrant at an annual
income at the level specified in section 213A(f)(l)(E) or section 213A(f)(3) of the INA.
If the Intending Immigrant Is a Household Member, Must He or She Execute This Contract?
If you are the intending immigrant and the sponsor is including your income on Form I-864 to meet the income
requirements in section 213A of the INA, you need to execute 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.

General Instructions

U.S. Citizenship and Immigration Services (USCIS) provides forms free of charge through the USCIS website. 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. You must be at least 18 years of age to act as a sponsor and sign
Form I-864A. 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-864A 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 U.S. Department of State (DOS), see www.travel.state.gov.
Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Specific
Instructions and/or What Evidence Must You Submit sections of these Instructions.

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Biometric Services Appointment. USCIS may require that you appear for an interview or provide fingerprints,
photograph, and/or signature at any time to verify your identity, obtain additional information, and conduct background
and security checks, including a check of criminal history records maintained by the Federal Bureau of Investigation
(FBI), before making a decision on your application, petition, or request. After USCIS receives your contract and ensures
it is complete, we will inform you in writing if you need to attend a biometric services appointment. If an appointment is
necessary, the notice will provide you the location of your local or designated USCIS Application Support Center (ASC)
and the date and time of your appointment or, if you are currently overseas, instruct you to contact a U.S. Embassy, U.S.
Consulate, or USCIS office outside the United States to set up an appointment.
If you are required to provide biometrics, at your appointment you must sign an oath reaffirming that:
1. You provided or authorized all information in the contract;

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2. You reviewed and understood all of the information contained in, and submitted with, your contract; and
3. All of this information was complete, true, and correct at the time of filing.

Copies. You should 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 USCIS requests an original document from you, it will be returned to
you after USCIS determines it no longer needs your original.
NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be
immediately destroyed upon receipt.
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. The certification must include the translator’s
signature. The Department of Homeland Security (DHS) recommends the certification contain the printed name and the
date and the translator’s contact information.
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.
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, Declaration, Certification, and Signature of this contract and the household member completes Parts 1. 4., and 6. The information below provides detailed information to help you complete this contract.
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.
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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 Numbers 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 Online Account Number (if any). If you have previously filed an application, petition, or
request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),
provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account
Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions,
or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice
issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be
found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The
USCIS Online Account Number is not the same as an A-Number.

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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. (intending immigrant and married to the sponsor), you do not have to reside with the
sponsor, but you must provide proof that your income will continue from a lawful source after immigration.
If you select Item Number 1.b. (intending immigrant and 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 a lawful source after
immigration.
If you select Item Number 1.c. (spouse of the sponsor and not the intending immigrant), you do not need to provide proof
that you have the same principal residence as the sponsor.
Part 3. Your (the Household Member’s) Employment and Income

Item Numbers 1. - 6. Your (the Household Member’s) Employment. Select all boxes that apply to you. A sponsor
may not rely on a household member’s income accrued or earned from unlawful activities or unlawful enterprises, such as
proceeds from illegal gambling or drug sales, to meet the income requirements, even if the household member paid taxes
on that income. A sponsor may not rely on a household member’s income from means-tested public benefits.
Item Number 7. Current Individual Annual Income. Enter your current individual earned or retirement annual income
that you are combining with the sponsor’s income to meet the income requirements and type or print the total on this line.
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 an 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 Internal Revenue Service (IRS)-issued certified copies or transcripts of your Federal individual
income tax return for the three most recent tax years.
Do not submit copies of your state or local 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 returns 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.
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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.
As stated previously, you must submit IRS-issued certified copies or transcripts of your Federal individual income tax
return for the three most recent tax years. If you were required to file a Federal income tax return for any of the three most
recent tax years but did not do so, you must file any and all late returns with the IRS and attach an IRS-issued certified
copy or transcript of each late return and submit it with Form I-864A. If you were not required to file Federal income tax
returns under U.S. tax law because your income was too low for any of the three most recent tax years, attach a typed or
printed explanation.

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If you were not required to file Federal income tax returns under U.S. tax law for any other reason for any of the three
most recent tax years, 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.
Obtaining Certified Copies of Taxes. You may use IRS Form 4506 to request certified copies of your taxes from the
IRS. Complete IRS Form 4506 with the ending date for each of your three most recent tax years listed on line 7. Follow
all instructions for completing and filing Form 4506 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.
Item Numbers 2.a. - 2.c. Most Recent Tax Year Total Income. Indicate the three most recent tax years and your Total
Income for those tax years. If that amount was zero for any year, enter “zero” or “N/A” for non-applicable.
Item Numbers 3.a. - 3.d. Assets. Complete this item only if the sponsor is using the value of your assets to help
meet the income requirements on Form I-864. If you are using only your income to help the sponsor meet the income
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 8., Item Numbers 6. - 10. of the Form I-864 and do not need to complete this
form.
Only assets that can be converted into cash within one year 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.
Item Numbers 4.a. - 9. Household Member’s Bank Account Information. Provide the account type, name(s) of all
account holders, the name of the banking institution, the account number of the checking or savings account, and the
corresponding routing number for the account that you are using to establish your financial eligibility.

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Item Number 10. Means-Tested Public Benefits Information. Indicate whether or not you have received any meanstested public benefits within the 36-month period before executing this Form I-864A. A means-tested public benefit is any
public benefit funded in whole or in part by funds provided by the Federal Government that has been determined to be a
Federal means-tested public benefit under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,
Public Law 104-193, or any public benefit for which no Federal funds are provided that a state, state agency, or political
subdivision of a state has determined to be a means-tested public benefit. No benefit shall be considered to be a meanstested public benefit if it is a benefit described in sections 401(b), 411(b), 422(b) or 423(d) of Public Law 104-193.
Item Number 11. Credit Report and Credit Score. You must provide a copy of a U.S. credit report and credit score
generated within the last 12 months prior to the date of submission, if available, with your Form I-864A.
You can obtain a free credit report once a year under the Fair Credit Reporting Act from each one of the three nationwide
credit reporting agencies (Equifax, Experian, and TransUnion). You are only required to provide one credit report and
credit score from any of the three nationwide credit reporting agencies. See https://www.usa.gov/credit-reports for
more information.

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If there are any errors in the credit report, you should provide evidence from the nationwide credit reporting agency that
demonstrates that you reported the error and that the error is under investigation or has been resolved. If you have any
negative history in your credit report, you may provide an explanation in the designated area of this form. Negative credit
history includes, but is not limited to, delinquent accounts, debt collections, charge-offs (delinquent accounts deemed
unlikely to be collected), repossession, foreclosure, judgments, tax liens, or bankruptcy reflected on your credit report.
If you do not have a credit report or credit score, provide documentation that demonstrates that you do not have a credit
report or score with any of the nationwide credit reporting agencies. You may provide evidence of continued payment of
bills if there is no credit report or credit score.
Part 5. Sponsor’s Promise, Statement, Contact Information, Declaration, Certification, and Signature
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 Numbers 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 Numbers 1.a. - 1.c., list any spouse and any and all 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 whether you read this contract yourself or whether you had an interpreter assist you.
If someone assisted you in completing the contract, select the box indicating that you used a preparer. 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, Declaration, 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 type or 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.”

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Select the appropriate box to indicate whether you read this contract yourself or whether you had an interpreter assist you.
If someone assisted you in completing the contract, select the box indicating that you used a preparer. 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 household member (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. - 7.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, his or her mobile telephone
number (if any), and his or her email address (if any). The interpreter must sign and date the contract.

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Part 8. Contact Information, Declaration, 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 sponsor or 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,
or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States,
along with your contract, if his or her representation extends beyond preparation of this contract.
Part 9. Additional Information

Item Numbers 1.a. - 7.d. 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. 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.
We recommend that you print or save a copy of your completed contract to review in the future and for
your records.

What Evidence Must 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 DOS, see
www.travel.state.gov.

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Where to File?
This contract MUST be filed with Form I-864.
For additional information, please see our USCIS website at www.uscis.gov/I-864 or call our 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 DOS, see www.travel.state.gov.

Address Change

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If you execute Form I-864A and are not a U.S. citizen or U.S. national, you must inform USCIS of your new address
within 30 days of moving from your previous residence. To do this, you must file Form I-865, Sponsor’s Change of
Address for Sponsors and Household Members.
If you execute Form I-864A and you are a U.S. citizen or a U.S. national, you must notify USCIS of your new address
within 30 days of moving from your previous residence. To do this, you must file Form I-865. For information on filing
Form I-865, go to the USCIS website at www.uscis.gov/i-864a or contact the USCIS 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.
For information on reporting a change of address to the Department of State, see www.travel.state.gov.
NOTE: Do not submit Form I-865 to the USCIS Lockbox facilities because the Lockbox does 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.
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. If USCIS requests an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.
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.

USCIS Forms and Information
To ensure you are using the latest version of this contract, visit the USCIS website 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 the USCIS Contact Center at 1-800-375-5283. The USCIS Contact Center provides information
in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

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Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at
www.uscis.gov. Select “Schedule an Appointment” and follow the screen prompts to set up your appointment. Once you
finish scheduling an appointment, the system will generate an appointment notice for you.

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.

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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 provide this notice because you were aware that the immigrants you sponsored had received Federal, state, or
local means-tested public benefits.
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 9. 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.

DHS Privacy Notice

AUTHORITIES: The information requested on this contract, and the associated evidence, is collected under the
Immigration and Nationality Act (INA) sections 212(a)(4) and 213A.
PURPOSE: The primary purpose for providing the requested information on this contract is to demonstrate that you, the
household member, meet the eligibility requirements to execute this contract between a household member and a sponsor
that imposes a legally enforceable obligation on the household member to assist the sponsor in supporting a sponsored
alien until the obligation terminates. DHS uses the information you provide as part of determining whether or not the
adjustment of status applicant or the immigrant visa applicant that you have agreed to help is eligible for the immigration
benefit.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number (if applicable), and any requested evidence, may delay a decision on whether the
sponsor’s Affidavit of Support Under Section 213A of the INA is found sufficient to meet the requirements of INA section
213A, or may result in the sponsor’s Affidavit of Support Under Section 213A of the INA being found insufficient.
ROUTINE USES: DHS may share the information you provide on this contract and any additional requested evidence
with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved
routine uses described in the associated published system of records notices [DHS/USCIS/ICE/CBP-001 Alien File
and National File Tracking System of Records, DHS/USCIS-007 Benefits Information System and DHS/USCIS-018
Immigration Biometric and Background Check] and the published privacy impact assessments [DHS/USCIS/PIA016a Computer Linked Application Information Management System and Associated Systems and DHS/USCIS/PIA056 USCIS Electronic Immigration System] 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.
Form I-864A Instructions 03/06/18 

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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 Office of Management and Budget (OMB) control number. The public
reporting burden for this collection of information is estimated at 2 hours and 15 minutes per response, 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 20529-2140; OMB No. 1615-0075. Do not mail your completed Form I-864A to this
address.

Checklist

Draft
Not for
Production
08/18/2020

The following items must be submitted with Form I-864A:
For ALL household members:

IRS-issued certified copies of your individual Federal income tax returns for the most three most recent tax years,
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 or reported income.
A copy of a U.S. credit report and credit score generated within the last 12 months prior to the date of filing.
For SOME sponsors:

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.

Form I-864A Instructions 03/06/18 

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