Many people who are unfamiliar with the Form I 864A Affidavit of Support might be wondering what this form is and when it is used. The Form I 864A Affidavit of Support is a document that is used to declare that a person has agreed to be responsible for the financial support of another person. This form is often used when one person immigrates to the United States and needs financial assistance from a sponsor in order to live in the country. The sponsor will complete and submit the form, as well as agree to provide any necessary financial support to the immigrant, in order for them to gain entry into the United States.
In the list, there is some information concerning the form i 864a affidavit of support. Our recommendation is that you look at this information before you decide to start editing the file.
Question | Answer |
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Form Name | Form I 864A Affidavit Of Support |
Form Length | 8 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min |
Other names | Form I-864A (PDF |
Contract Between Sponsor and Household Member |
USCIS |
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Form |
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Department of Homeland Security |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 09/30/2021 |
For Government Use Only
This Form
IS the intending |
IS NOT the |
Reviewed By: |
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immigrant |
intending |
Location: |
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Date (mm/dd/yyyy): |
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immigrant |
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To be completed by an |
Select this box if |
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Attorney State Bar Number |
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Attorney or Accredited Representative |
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(if applicable) |
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USCIS Online Account Number (if any) |
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attorney or accredited |
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representative (if any). |
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►START HERE - Type or print in black ink.
Part 1. Information About You (the Household Member)
Full Name
1.a. Family Name
(Last Name)
Physical Address
4.a. Street Number
and Name
4.b. Apt. Ste. Flr.
4.c. City or Town
1.b. Given Name (First Name)
1.c. Middle Name
Mailing Address
2.a. In Care Of Name
2.b. Street Number
4.d. State
4.f. Province
4.g. Postal Code
4.h. Country
4.e. ZIP Code
and Name
2.c. Apt. Ste. Flr.
2.d. City or Town
2.e. State |
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2.f. ZIP Code |
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2.g. Province
2.h. Postal Code
2.i. Country
3.Is your current mailing address the same as your physical
address? |
Yes |
No |
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If you answered "No" to Item Number 3., provide your physical address.
Other Information
5.Date of Birth (mm/dd/yyyy)
Place of Birth 6.a. City or Town
6.b. State or Province
6.c. Country
7.U.S. Social Security Number (if any)
►
8.USCIS Online Account Number (if any)
►
Form |
Page 1 of 8 |
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)
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 |
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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
three most recent tax years? |
Yes |
No |
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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 |
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of my Federal income tax returns for my second and |
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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:
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Tax Year |
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Total Income |
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2.a. |
Most Recent |
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$ |
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2.b. |
2nd Most Recent |
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$ |
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2.c. |
3rd Most Recent |
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$ |
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My assets (complete only if necessary). |
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3.a. |
Enter the balance of all cash, savings, and checking |
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accounts. |
$ |
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3.b. |
Enter the net cash value of |
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value means assessed value minus mortgage debt.) |
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$ |
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3.c. |
Enter the cash value of all stocks, bonds, certificates of |
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deposit, and other assets not listed on Item Numbers 3.a. |
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or 3.b. |
$ |
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3.d. |
Add together Item Numbers 3.a., 3.b., and 3.c. and enter |
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the number here. |
$ |
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Part 5. Sponsor's Promise, Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form
I, THE SPONSOR,
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(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)
Form |
Page 2 of 8 |
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-
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-
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-
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-
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-
24.U.S. Social Security Number (if any)
►
25.USCIS Online Account Number (if any)
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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.
Form |
Page 3 of 8 |
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
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a language in which I am fluent, and I understood |
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everything. |
27. |
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
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, 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
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
Form |
Page 4 of 8 |
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
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 |
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and understand every question and instruction on this |
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contract and my answer to every question. |
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1.b. |
The interpreter named in Part 7. read to me every |
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question and instruction on this contract and my |
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answer to every question in |
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a language in which I am fluent, and I understood |
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everything. |
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2. |
At my request, the preparer named in Part 8., |
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prepared this contract for me based only upon |
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information I provided or authorized. |
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)
Form |
Page 5 of 8 |
Part 7. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
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.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
3.d. State
3.f. Province
3.g. Postal Code
3.h. Country
3.e. ZIP Code
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
Interpreter's Contact Information
4. |
Interpreter's Daytime Telephone Number |
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and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
5. |
Interpreter's Mobile Telephone Number (if any) |
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6. |
Interpreter's Email Address (if any) |
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Interpreter's Certification
I certify, under penalty of perjury, that:
3.d. State
3.f. Province
3.g. Postal Code
3.h. Country
3.e. ZIP Code
I am fluent in English and |
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which is the same language specified in Part 5., Item Number 26.b. or Part 6., Item Number 1.b., and I have read to this sponsor or household member in the identified language every question and instruction on this contract and his or her answer to every question. The sponsor or household member informed me that he or she understands every instruction, question, and answer on the contract, including the Sponsor's or Household Member's Declaration and Certification, and has verified the accuracy of every answer.
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)
Form |
Page 6 of 8 |
Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Contract, if Other Than the Sponsor or Household Member (continued)
Preparer's Statement
7.a. |
I am not an attorney or accredited representative but |
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have prepared this contract on behalf of the sponsor |
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and household member and with the sponsor's or |
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household member's consent. |
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7.b. |
I am an attorney or accredited representative and my |
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representation of the sponsor and household member |
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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
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this contract at the request of the sponsor and household member. The sponsor and household member then reviewed this completed contract and informed me that he or she understands all of the information contained in, and submitted with, his or her contract, including the Sponsor's or Household Member's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this contract based only on information that the sponsor and household member provided to me or authorized me to obtain or use.
Preparer's Signature
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Form |
Page 7 of 8 |
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
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
► 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.
Form |
Page 8 of 8 |