Form I-864A Contract Between Sponsor and Household Member

USCIS
Form I-864A

Contract Between Sponsor and Household Member
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0075
Expires 01/31/2026

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

IS NOT the
intending
immigrant

Reviewed By:
Location:

Date (mm/dd/yyyy):

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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.

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

Family Name (Last Name)

Mailing Address
2.

Middle Name (if applicable)

(USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Given Name (First Name)

Postal Code

ZIP Code

Country

Yes

Is your current mailing address the same as your physical address?

No

If you answered "No" to Item Number 3., provide your physical address.

Physical Address
4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-864A 01/23/24

Postal Code

ZIP Code

Country

Page 1 of 8

Part 1. Information About You (the Household Member) (continued)
Other Information
5.

Date of Birth (mm/dd/yyyy)

6.

7.

Country of Birth

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

8.

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

9.

USCIS Online Account Number (if any)
►

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Part 2. Your (the Household Member's) Relationship to the Sponsor
Select Item Number 1., 2., or 3.
1.

I am the intending immigrant and also the sponsor's spouse.

2.

I am the intending immigrant and also a member of the sponsor's household.

3.

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)

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 Since (mm/dd/yyyy)

6.

Unemployed since (mm/dd/yyyy)

7.

My current individual annual income is:

Form I-864A 01/23/24

$

Page 2 of 8

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 a photocopy or transcript of your 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
2.

Total Income

Most Recent

$

2nd Most Recent

$

3rd Most Recent

$

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My assets (complete only if necessary).
3.

Enter the balance of all cash, savings, and checking accounts.

$

4.

Enter the net cash value of real-estate holdings. (Net value means assessed value minus mortgage
debt.) $

$

5.

Enter the cash value of all stocks, bonds, certificates of deposit, and other assets not listed on
Item Numbers 3. - 4.

$

6.

Add together Item Numbers 3. - 5. and enter the number here.

$

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,

,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.
1.

Intending Immigrant Number 1
Family Name (Last Name)

Date of Birth (mm/dd/yyyy)

2.

Middle Name (if applicable)

Alien Registration Number (A-Number, if any) USCIS Online Account Number (if any)
►
►

Intending Immigrant Number 2
Family Name (Last Name)

Date of Birth (mm/dd/yyyy)

3.

Given Name (First Name)

Given Name (First Name)

Middle Name (if applicable)

Alien Registration Number (A-Number, if any) USCIS Online Account Number (if any)
►
►

Intending Immigrant Number 3
Family Name (Last Name)

Date of Birth (mm/dd/yyyy)

Form I-864A 01/23/24

Given Name (First Name)

Middle Name (if applicable)

Alien Registration Number (A-Number, if any) USCIS Online Account Number (if any)
►
►

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Part 5. Sponsor's Promise, Statement, Contact Information, Declaration, Certification, and Signature
(continued)
4.

Intending Immigrant Number 4
Family Name (Last Name)

Date of Birth (mm/dd/yyyy)

Given Name (First Name)

Middle Name (if applicable)

Alien Registration Number (A-Number, if any) USCIS Online Account Number (if any)
►
►

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Sponsor's Statement

NOTE: Select the box for either Item Number 5.a. or 5.b. If applicable, select the box for Item Number 6.
5.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.

5.b.

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

6.

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

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

, prepared this contract for

me based only upon information I provided or authorized.

Sponsor's Contact Information
7.

Sponsor's Daytime Telephone Number

9.

Sponsor's Email Address (if any)

8.

Sponsor's Mobile Telephone Number (if any)

Sponsor's Declaration and Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S.
Citizenship and Immigration Services (USCIS) or the U.S. Department of State (DOS) may require that I submit original documents
to USCIS or DOS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS
or DOS may need to determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this contract, in supporting documents, and in my USCIS or DOS records,
to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that all of the information in my contract and any document submitted with it were provided or
authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my contract and that all of
this information is complete, true, and correct.

Sponsor's Signature
10.

Sponsor's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL SPONSORS: If you do not completely fill out this contract or fail to submit required documents listed in the
Instructions, USCIS may deny your contract.

Form I-864A 01/23/24

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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

, in consideration of the sponsor's promise to complete

and file an affidavit of support on behalf of the above named intending immigrants.

(Print number of intending

immigrants noted in Part 5. Sponsor's Promise, Statement, Contact Information, Declaration, Certification, and Signature.)

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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.

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

2.

, prepared this contract

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

Your (the Household Member's) Contact Information
3.

Your (the Household Member's) Daytime Telephone Number

5.

Your (the Household Member's) Email Address (if any)

Form I-864A 01/23/24

4.

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

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

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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.

Your (the Household Member's) Signature
6.

Your (the Household Member's) Printed Name

7.

Your (the Household Member's) Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL HOUSEHOLD MEMBERS: If you do not completely fill out this contract or fail to submit required documents
listed in the Instructions, USCIS may deny your contract.

Part 7. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Form I-864A 01/23/24

4.

Interpreter's Mobile Telephone Number (if any)

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Part 7. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Certification
I certify, under penalty of perjury, that: that I am fluent in English and

, and I have interpreted every

question on the contract and instructions and interpreted the sponsor's or household member's answers to the questions in that
language and the sponsor or household member informed me that he or she understood every instruction, question, and answer on the
contract.

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Interpreter's Signature
6.

Date of Signature (mm/dd/yyyy)

Interpreter's Signature

Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Contract, if Other
Than the Sponsor or Household Member
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this contract for the sponsor and household member at their request and with express
consent and that all of the responses and information contained in and submitted with the contract are complete, true, and correct and
reflects only information provided by the sponsor and household member. The sponsor and household member reviewed the
responses and information and informed me that they understand the responses and information in or submitted with the contract.
6.

Preparer's Signature

Form I-864A 01/23/24

Date of Signature (mm/dd/yyyy)

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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.
1.

Family Name (Last Name)

Given Name (First Name)

2.

A-Number (if any) ► A-

3.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

Middle Name (if applicable)

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Form I-864A 01/23/24

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