I-864A Form TOC

TABLE OF CHANGES – FORM

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 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. 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, but not married to the sponsor. 1.c. [ ] I am not the intending immigrant. I am the sponsor's spouse. [deleted]
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.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. 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: 2.a. Most Recent Tax Year Total Income $ 2.b. 2nd Most Recent Tax Year Total Income $ 2.c. 3rd Most Recent Tax Year Total Income $ 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. Have you filed a Federal income tax return for each of the three most recent tax years? Yes/No NOTE: You MUST attach IRS-issued certified copies or transcripts of your Federal income tax return for the three most recent tax years. [deleted] 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: 2.a. Most Recent Tax Year Total Income $ 2.b. 2nd Most Recent Tax Year Total Income $ 2.c. 3rd Most Recent Tax Year Total Income $ 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. $ Household Member’s Bank Account Information Account Type 4.a. Checking 4.b. Savings Account Holder 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name Joint Account Holder (if any) 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name 7. Institution Name 8. Account Number 9. Routing Number Means-Tested Public Benefits 10. I have received a means-tested public benefit within 36 months of filing this Form I-864. Y/N Credit Report and Credit Score Information Provide documentation as provided in the Instructions. 11. Do you have a U.S. credit report and credit score available? _ Yes. Provide a copy of a U.S. credit report and credit score generated within the last 12 months prior to the date of filing. __ No. Provide a credit agency report that demonstrates that you do not have a credit report or score.
Pages 2-4, Part 5. Sponsor's Promise, Statement, Contact Information, Declaration, Certification, and Signature	[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 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 execute an affidavit of support on behalf of the following named intending immigrants. [fillable box (Indicate Number)] …
Pages 4-5, Part 6. Your (the Household Member's) Promise, Statement, Contact Information, Declaration, Certification, and Signature	[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; B. Agree to be jointly and severally liable for payment of any and all obligations owed by the sponsor under the affidavit of support to the sponsored immigrants, to any agency of the Federal Government, to any agency of a state or local government, or to any other private entity that provides means-tested public benefits; C. Certify under penalty under the laws of the United States that the Federal income tax returns submitted in support of the contract are true copies or unaltered tax transcripts filed with the Internal Revenue Service; D. Consideration where the household member is also the sponsored immigrant: I understand that if I am the sponsored immigrant and a member of the sponsor's household that this promise relates only to my promise to be jointly and severally liable for any obligation owed by the sponsor under the affidavit of support to any of my dependents, to any agency of the Federal Government, to any agency of a state or local government, or to any other private entity that provides means-tested public benefits and to provide any and all financial support necessary to assist the sponsor in maintaining any of my dependents at or above the minimum income provided for in INA section 213A(a)(1)(A) (not less than 125 percent of the Federal Poverty Guideline) during the period which the affidavit of support is enforceable. [Page 5] 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). …	[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 execute 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] G. I understand that if I do not file a properly completed Form I-865 within 30 days of any change of address, USCIS may impose a civil fine for my failing to do so. …

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