Form I-864A

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

Form I-864A

Form I-864A, Contract Between Sponsor and Household Member, is an attachment to Form I-864, Affidavit of Support Under Section 213A of the INA. A separate Form I-864A must be used for each household member whose income and/or assets are being used by a sponsor to qualify. Each Form I-864A is completed and signed by two individuals: a sponsor who is completing Form I-864 and a household member who is promising to make his or her income and/or assets available to the sponsor to help support the sponsored immigrants. The combined signing of this contract constitutes an agreement that the household member is responsible along with the sponsor for the support of the individuals named in this contract.



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Information


Part 1. Information About You (the Household Member)

Full Name Mailing Address Is your current mailing address the same as your physical address? Physical Address Other Information

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

Select the item


Part 3. Your (the Household Member's) Employment and Income

I am currently

Part 4. Your (the Household Member's) Federal Income Tax Information and Assets

Have you filed a Federal income tax return for each of the three 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:
Tax year Total income
Most Recent
2nd Most Recent
3rd Most Recent

Forms

Part 5. Sponsor's Promise, Statement, Contact Information, Declaration, Certification, and Signature

Intending Immigrant Number 1 Intending Immigrant Number 2 Intending Immigrant Number 3 Intending Immigrant Number 4 Intending Immigrant Number 5 Sponsor's Contact Information Your (the Household Member's) Contact Information

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

Interpreter's Full Name Interpreter's Mailing Address
Interpreter's Contact Information

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 Preparer's Mailing Address
Preparer's Contact Information

Complete

You will pay a total of $10
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