I-864a Ins Toc

TABLE OF CHANGES – INSTRUCTIONS

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

OMB Number: 1615-0075

08/18/2020

Reason for Revision: Affidavit of Support NPRM.

Project Phase: DHSReview

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 03/31/2020

Edition Date 03/06/2018

Current Page Number and Section	Current Text	Proposed Text
Page 1, What Is the Purpose of Form I-864A?	[Page 1] What Is the Purpose of Form I-864A? Form I-864A, Contract Between Sponsor and Household Member, is an attachment to Form I-864, Affidavit of Support Under Section 213A of the INA. A separate Form I-864A must be used for each household member whose income and/or assets are being used by a sponsor to qualify. Each Form I-864A is completed and signed by two individuals: a sponsor who is completing Form I-864 and a household member who is promising to make his or her income and/or assets available to the sponsor to help support the sponsored immigrants. The combined signing of this contract constitutes an agreement that the household member is responsible along with the sponsor for the support of the individuals named in this contract. This contract must be submitted with Form I-864. Form I-864A may only be used when a sponsor’s income and assets do not meet the income requirements of Form I-864 and the qualifying household member chooses to combine his or her resources with the income and/or assets of a sponsor to meet the requirements. The obligations of the household member under this contract terminate when the obligations of the sponsor under the Affidavit of Support terminate. For additional information, see the Immigration and Nationality Act (INA) section 213A and part 213a of Title 8 of the Code of Federal Regulations. What Is a Sponsor? A sponsor is: 1. The petitioning relative; 2. A relative with a significant ownership interest in the petitioning entity; or 3. A substitute in the case of a deceased petitioner, or another person accepting joint and several liability with the sponsor; AND 4. Someone who completes and files Form I-864 on behalf of an intending immigrant. A sponsor must be an individual and may not be an enterprise, a business, or any other type of organization. Who May Be Considered a Household Member for Purposes of Form I-864A? For purposes of this contract, one or more of the following individuals may sign the Form I-864A as a household member if at least 18 years of age: 2. The spouse, parent, child, adult son or daughter, or sibling relative of the sponsor, if that relative has the same principal residence as the sponsor; or 1. 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; 3. Any other individual whom the sponsor has lawfully claimed as a dependent on the sponsor’s most recent Federal income tax return even if that person does not live at the same residence as the sponsor. If more than one individual agrees to help support the sponsored immigrant, each individual must sign a separate Form I-864A. How Can the Intending Immigrant Be Considered a Household Member? Listed below are two ways that the intending immigrant may be considered to be a household member for the purposes of pooling income with the sponsor to meet the Affidavit of Support requirements: [Page 2] 1. The intending immigrant has the same principal residence as the sponsor and the intending immigrant can establish that his or her income will continue from a lawful source, even after acquisition of lawful permanent residence; or 2. The intending immigrant is the sponsor’s spouse and the intending immigrant can show that his or her income will continue from a lawful source after acquisition of lawful permanent residence. Why Does a Household Member Complete Form I-864A? A household member completes this contract if the household member’s income and/or assets will be used to demonstrate the sponsor’s ability to meet the income requirements and to maintain the sponsored immigrant at an annual income at the level specified in INA section 213A(f)(l)(E) or section 213A(f)(3). If the Intending Immigrant Is a Household Member, Must He or She Complete This Contract? If you are the intending immigrant and the sponsor is including your income on Form I-864 to meet the eligibility requirements, you need to complete this contract only if you have accompanying dependents. If you are the intending immigrant and the sponsor is including only your assets on Form I-864, you do not need to complete this contract, even if you have accompanying dependents.	[Page 1] 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. 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. [no changes] 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. [no changes] 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. [deleted] 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: [Page 2] 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. 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.
Pages 3-7, Specific Instructions	[Page 3] Specific Instructions … Part 2. Your (the Household Member’s) Relationship to the Sponsor Item Numbers 1.a. - 1.c. Select the item which best reflects your relationship to the sponsor. If you select Item Number 1.a. (married to the sponsor), you do not have to reside with the sponsor, but you must provide proof that your income will continue from a lawful source after immigration. If you select Item Number 1.b. (not married to the sponsor), you must provide proof that you currently have the same principal residence as the sponsor and that your income will continue from a lawful source after immigration. If you are the household member completing this contract, but are not the intending immigrant, select Item Number 1.c., and select the box below that describes your relationship to the sponsor. If you select “Other Dependent,” you must be listed as a dependent on the sponsor’s most recent Federal income tax return. You do not have to provide proof that you have the same principal residence as the sponsor. If you select any other relative except for spouse, you must provide proof of the relationship and that you have the same principal residence as the sponsor. Part 3. Your (the Household Member’s) Employment and Income Item 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 from illegal activities, such as proceeds from illegal gambling or drug sales, to meet the income requirements, even if the household member paid taxes on that income. Item Number 7. Current Individual Annual Income. Enter your current individual earned or retirement annual income that you are using to meet the requirements of this contract and 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 an Internal Revenue Service (IRS) transcript or a photocopy from your own records of your Federal individual income tax return for the most recent tax year. If you believe additional returns may help you to establish your ability to maintain sufficient income, you may submit transcripts or photocopies of your Federal individual income tax returns for the three most recent years. You are not required to have the IRS certify the transcript or photocopy unless specifically instructed to do so by a government official; a plain transcript or photocopy is acceptable. Do not submit copies of your state income tax returns. Do not submit any tax returns that you filed with any foreign government unless you are claiming that you were not required to file a Federal income tax return with the United States Government and you wish to rely on the foreign return solely to establish the amount of your income that was not subject to tax in the United States. [Page 5] If you provide a photocopy of your tax returns, you must include a copy of each and every Form W-2 and Form 1099 that relates to your returns. Do not include copies of these forms if you provide an IRS transcript of your returns rather than a photocopy unless you filed a joint Federal income tax return with your spouse. If you selected Item Number 1.b. in Part 3., that you are self-employed, you should have completed one of the following forms with your Federal income tax return: Schedule C (Profit or Loss from Business), Schedule D (Capital Gains), Schedule E (Supplemental Income or Loss), or Schedule F (Profit or Loss from Farming). You must include each and every Form 1040 Schedule, if any, that you filed with your Federal income tax return. As stated previously, you must submit an IRS transcript or copy of your Federal individual income tax return for the most recent tax year. If you choose to rely on income from the three most recent tax years, you must submit an IRS transcript or copy of your Federal individual income tax return. If you were required to file a Federal income tax return for that tax year but did not do so, you must file any and all late returns with the IRS and attach an IRS transcript or copy of your late return and submit it with Form I-864A. If you were not required to file a Federal income tax return under U.S. tax law because your income was too low, attach a typed or printed explanation. If you were not required to file a Federal income tax return under U.S. tax law for any other reason, attach a typed or printed explanation including evidence of the exemption and how you qualified for it. Residence outside of the United States does not exempt U.S. citizens or lawful permanent residents from filing a U.S. Federal income tax return. See Filing Requirements in the IRS Form 1040 Filing Instructions to determine whether you were required to file. For purposes of this contract, the line for Total Income on IRS Forms 1040 and 1040A will be considered when determining income. For persons filing IRS Form 1040 EZ, the line for Adjusted Gross Income will be considered. Obtaining Tax Transcripts. You may use IRS Form 4506-T to request tax transcripts from the IRS. Complete IRS Form 4506-T with the ending date for each of your three most recent tax years listed on line 9. Follow all instructions for completing and filing Form 4506-T with the IRS. Item Number 1. Select the box if you filed a Federal income tax return for each of the three most recent tax years and have attached the required photocopy or transcript of your Federal income tax return for only the most recent year. Item Numbers 2.a. - 2.c. Most Recent Tax Year Total Income. Indicate the most recent tax year and your Total Income for that most recent tax year. If that amount was zero, enter “zero” or “N/A” for non-applicable. If applicable, select the Optional box indicating that you have attached photocopies or transcripts of your Federal income tax returns for your second and third most recent tax years. Item Numbers 3.a. - 3.d. Assets. Complete this item only if the sponsor is using the value of your assets to help meet the requirements of the affidavit of support. If you are using only your income to help the sponsor meet the requirements, do not complete this item. If you are the intending immigrant and have no accompanying dependents, then do not list your assets on this contract. Instead, you must list your assets in Part 7., Item Numbers 6. - 10. of the Form I-864 and do not need to complete this form. Only assets that can be converted into cash within one year and without considerable hardship or financial loss to the owner may be included. The owner of the asset must include a description of the asset, proof of ownership, and the basis for the owner’s claim of its net cash value. You may include the net value of your home as an asset. The net value of the home is the appraised value of the home, minus the sum of any and all loans secured by a mortgage, trust deed, or other lien on the home. If you wish to include the net value of your home, you must include documentation demonstrating that you own it, a recent appraisal by a licensed appraiser, and evidence of the amount of any and all loans secured by a mortgage, trust deed, or other lien on the home. You may not include the net value of an automobile unless you show that you have more than one automobile, and at least one automobile is not included as an asset. …	[Page 3] Specific Instructions [no changes] 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. [no change] 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. [deleted] 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. [Page 5] [deleted] 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. 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. Item Number 10. Means-Tested Public Benefits Information. Indicate whether or not you have received any means-tested 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 means-tested 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. 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. [no changes]
Page 7, Address Change	[Page 7] Address Change A sponsor who is not a U.S. citizen must inform USCIS of his or her new address within 10 days of moving from his or her previous residence. For reporting a change of address to USCIS, you must complete and file Form I-865, Sponsor’s Change of Address. For information on filing Form I-865, go to the USCIS website at www.uscis.gov/I-865 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. This requirement does not relieve a lawful permanent resident sponsor from filing a change of address within 10 days of the change. For information on filing a change of address, go to the USCIS website at www.uscis.gov/addresschange or contact the National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833. For information on reporting a change of address to the Department of State, see www.travel.state.gov. NOTE: Do not 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. NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not process change of address requests.	[Page 7] Address Change 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.
Page 8, Penalties	[Page 8] Penalties If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-864A, we will deny your Form I-864A and may deny any other immigration benefit. In addition, you will face severe penalties provided by law and may be subject to criminal prosecution. The government may pursue verification of any information provided on or in support of this contract, including employment, income, or assets with the employer, financial or other institutions, the IRS, or the Social Security Administration. If you include in this contract any information that you know to be false, you may be liable for criminal prosecution under the laws of the United States. If you fail to give notice of your change of address, as required by 8 U.S.C. 1183a(d) and 8 CFR 213a.3, you may be liable for the civil penalty established by 8 U.S.C. 1183a(d)(2). The amount of the civil penalty will depend on whether you failed to 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 8. of Form I-864,) such failure may result in a fine of not less than $2,000 or more than $5,000. Otherwise, the failure to report your change of address may result in a fine not less than $250 or more than $2,000.	[Page 8] Penalties If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-864A, we will deny your Form I-864A and may deny any other immigration benefit. In addition, you will face severe penalties provided by law and may be subject to criminal prosecution. The government may pursue verification of any information provided on or in support of this contract, including employment, income, or assets with the employer, financial or other institutions, the IRS, or the Social Security Administration. If you include in this contract any information that you know to be false, you may be liable for criminal prosecution under the laws of the United States. If you fail to give notice of your change of address, as required by 8 U.S.C. 1183a(d) and 8 CFR 213a.3, you may be liable for the civil penalty established by 8 U.S.C. 1183a(d)(2). The amount of the civil penalty will depend on whether you failed to 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.
Page 9, USCIS Privacy Act Statement	[Page 9] USCIS Privacy Act Statement AUTHORITIES: The information requested on this contract, and the associated evidence, is collected under the Immigration and Nationality Act section 213A. PURPOSE: The primary purpose for providing the requested information on this contract is to show that the applying immigrant has adequate means of financial support without concern of becoming reliant on the U.S. Government for financial support. DHS will use the information you provide to grant or deny the immigration benefit you are seeking. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision in your case or result in denial of your contract. INA section 213A(i) requires the collection of your Social Security number. Failure to provide the requested information, and any requested evidence, may prevent USCIS from accepting and approving this contract, and the intending immigrant may not be able to immigrate to the United States. ROUTINE USES: The Department of Homeland Security (DHS) may share the information you provide on this contract with other Federal, state, local, and foreign government agencies and authorized organizations. Social Security numbers may be verified with the Social Security Administration. DHS follows approved routine uses described in the associated published system of records notices [DHS/USCIS-007 - Benefits Information System and DHS/USCIS-001 - Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.	[Page 9] 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/PIA-016a Computer Linked Application Information Management System and Associated Systems and DHS/USCIS/PIA-056 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.
Page 11	[Page 11] 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 1 hour and 45 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.	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.
Page 10, Checklist	[Page 10] Checklist The following items must be submitted with Form I-864A: For ALL sponsors: [] A copy of your individual Federal income tax return, including W-2s for the most recent tax year, or a statement and/or evidence describing why you were not required to file. Also include a copy of each and every Form 1099, Schedule, and any other evidence or reported income. You may submit this information for the most recent three tax years, pay stubs from the most recent six months, and/or a letter from your employer if you believe any of these items will help you qualify. For SOME sponsors: 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.	[Page 10] Checklist 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 household members: 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.

1