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

Under Full Name, enter Family Name (Last Name), Given Name (First Name) and Middle Name (if applicable).

Under Mailing Address, enter In Care Of Name (if any), Street Number and Name, Flr. Ste. Apt. Number, City or Town, State, ZIP Code, Postal Code, Country and Province.

Item Number 3. Is your current mailing address the same as your physical address? No Yes. If you answered "No" to Item Number 3., provide your physical address under Physical Address.

Under Other Information, enter Date of Birth (mm/dd/yyyy), Country of Birth, U.S. Social Security Number (if any), Alien Registration Number (A-Number) (if any) and USCIS Online Account Number (if any).

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).

The intending immigrant may sign the Form I-864A as a household member if at least 18 years of age, when 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.⁠^[2]

I am currently: Employed as a/an, with Name of Employer Number 1 and Name of Employer Number 2 (if applicable); Self employed as a/an; Retired Since (mm/dd/yyyy); Unemployed since (mm/dd/yyyy).

Enter My current individual annual income.

Part 4. Have you filed a Federal income tax return for each of the three most recent tax years? Yes No

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.

My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal income tax returns for the most recent three years: enter Tax Year and Total Income for Most Recent, 2nd Most Recent and 3rd Most Recent. Indicate the most recent tax year and your Total Income for that most recent tax year.⁠^[2]

Complete this item only if the sponsor is using the value of your assets to help meet the requirements of the affidavit of support. Only assets that can be converted into cash within one year and without considerable hardship or financial loss to the owner may be included.

Complete only if necessary: enter the balance of all cash, savings, and checking accounts.

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

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.⁠^[2]

For each of Intending Immigrant Number 1, 2, 3 and 4, enter Family Name (Last Name), Given Name (First Name), Middle Name (if applicable), Alien Registration Number (A-Number, if any), Date of Birth (mm/dd/yyyy) and USCIS Online Account Number (if any).

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 4., Item Number 1. of his or her Form I-864), you should list the intending immigrant in Part 5., Item Number 1. 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.⁠^[2]

Part 6. Read the Penalties section of the Form I-864A Instructions before completing this part.

The household member promises 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. Print the number of intending immigrants noted in Part 5.

The household member agrees 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.

If the household member is 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 the household member of the obligations under this Form I-864A.

The household member certifies 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.

Your (the Household Member's) Statement: 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. At my request, the preparer named in Part 8., prepared this contract for me based only upon information I provided or authorized.

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 Part 7. and sign and date the contract.

The person who completed your contract, if other than you, the sponsor or household member, must sign Part 8.⁠^[2]

Under Your (the Household Member's) Contact Information, you must sign and date your contract and provide your daytime telephone number, mobile telephone number (if any), and email address (if any).⁠^[2]

The household member certifies, under penalty of perjury, that all of the information in the contract and any document submitted with it were provided or authorized by the household member and that all of this information is complete, true, and correct. 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.⁠^[2]