Form I-864A – Fill Out and Use This PDF

IS the intending immigrant

Part 1. Information About You (the Household Member)

Physical Address

4.a. Street Number

and Name

Full Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2.a. In Care Of Name

4.b. Apt. 4.c. City or Town 4.d. State

4.f. Province

4.g. Postal Code

4.h. Country

Ste. Flr.

4.e. ZIP Code

2.b. Street Number

and Name

Other Information

2.c. Apt. 2.d. City or Town 2.e. State

2.g. Province

2.h. Postal Code

2.i. Country

Ste. Flr.

2.f. ZIP Code

5.Date of Birth (mm/dd/yyyy)

Place of Birth 6.a. City or Town

6.b. State or Province

6.c. Country

3.Is your current mailing address the same as your physical

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

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

►

8.USCIS Online Account Number (if any)

►

Part 2. Your (the Household Member's) Relationship to the Sponsor

Select Item Number 1.a., 1.b., or 1.c.

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 from (Company Name)

Since (mm/dd/yyyy)

6. Unemployed since (mm/dd/yyyy)

7.My current individual annual income is:

$

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

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:

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.

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,

,

(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.

(Indicate Number)

Part 5. Sponsor's Promise, Statement, Contact

Information, Declaration, Certification, and

Signature (continued)

Intending Immigrant Number 1

Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2. Date of Birth (mm/dd/yyyy)

3.Alien Registration Number (A-Number, if any)

► A-

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

►

5.USCIS Online Account Number (if any)

►

Intending Immigrant Number 2

Name

6.a. Family Name

(Last Name)

6.b. Given Name

(First Name)

6.c. Middle Name

7. Date of Birth (mm/dd/yyyy)

8.Alien Registration Number (A-Number, if any)

► A-

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

►

10.USCIS Online Account Number (if any)

►

Intending Immigrant Number 3

Name

11.a. Family Name

(Last Name)

11.b. Given Name

(First Name)

11.c. Middle Name

12. Date of Birth (mm/dd/yyyy)

13.Alien Registration Number (A-Number, if any)

► A-

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

►

15.USCIS Online Account Number (if any)

►

Intending Immigrant Number 4

Name

16.a. Family Name

(Last Name)

16.b. Given Name

(First Name)

16.c. Middle Name

17. Date of Birth (mm/dd/yyyy)

18.Alien Registration Number (A-Number, if any)

► A-

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

►

20.USCIS Online Account Number (if any)

►

Intending Immigrant Number 5

Name

21.a. Family Name

(Last Name)

21.b. Given Name

(First Name)

21.c. Middle Name

22. Date of Birth (mm/dd/yyyy)

23.Alien Registration Number (A-Number, if any)

► A-

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

►

25.USCIS Online Account Number (if any)

►

Sponsor's Statement

NOTE: Select the box for either Item Number 26.a. or 26.b. If applicable, select the box for Item Number 27.

26.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.

Part 5. Sponsor's Promise, Statement, Contact

Information, Declaration, Certification, and

Signature (continued)

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

,

,

prepared this contract for me based only upon information I provided or authorized.

Sponsor's Contact Information

28.Sponsor's Daytime Telephone Number

29.Sponsor's Mobile Telephone Number (if any)

30.Sponsor's Email Address (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

31.a. Sponsor's Signature

31.b. 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.

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,

,

(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.

(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.

Part 6. Your (the Household Member's) Promise,

Statement, Contact Information, Declaration,

Certification, and Signature (continued)

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.

Your (the Household Member's) Contact Information

3.Your (the Household Member's) Daytime Telephone Number

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

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

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.

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.a. Your (the Household Member's) Printed Name

6.b. Your (the Household Member's) Signature

6.c. 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

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.Interpreter's Business or Organization Name (if any)

Part 7. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Mailing Address

Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Contract, if Other Than the Sponsor or Household Member

Provide the following information about the preparer.

3.a. Street Number

and Name

3.b. Apt. 3.c. City or Town 3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

Ste. Flr.

3.e. ZIP Code

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number

and Name

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (if any)

Interpreter's Certification

3.b. Apt. 3.c. City or Town 3.d. State

3.f. Province

3.g. Postal Code

3.h. Country

Ste. Flr.

3.e. ZIP Code

Interpreter's Signature

7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

7.a.

7.b.

I am not an attorney or accredited representative but have prepared this contract on behalf of the sponsor and household member and with the sponsor's or household member's consent.

I am an attorney or accredited representative and my representation of the sponsor and household member in this case extends does not extend beyond

the preparation of this contract.

NOTE: If you are an attorney or accredited representative, you may be obliged to 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, with this contract.

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.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name

2.A-Number (if any)

► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.