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Contract Between Sponsor And Household Member I-864A - Official Federal Forms
| Contract Between Sponsor And Household Member Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0075; Expires 03/31/2015 Department of Homeland Security U.S. Citizenship and Immigration Services I-864A, Contract Between Sponsor and Household Member For Government Use Only Part 1. Information on the Household Member. (You.) 1. Name Last Name First Name 2. Mailing Address Middle Name This I-864A relates to a household member who: is the intending immigrant. Street Number and Name (include apartment number) City Country State or Province Zip/Postal Code is not the intending immigrant. 3. Place of Residence (if different from mailing address) Street Number and Name (include apartment number) City Country State or Province Zip/Postal Code Location Reviewer 4. Telephone Number 5. Date of Birth 6. Place of Birth 7. U.S. Social Security Number (if any) (Include area code or country and city codes) (mm/dd/yyyy) City State/Province Country Date (mm/dd/yyyy) 8. Relationship to Sponsor (Check either a, b or c.) a. b. c. I am the intending immigrant and also the sponsor's spouse. I am the intending immigrant and also a member of the sponsor's household. 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 old) Parent Brother or sister Other dependent (specify) Form I-864A (03/22/13) Y American LegalNet, Inc. www.FormsWorkFlow.com 9. I am currently: For Government Use Only a. Employed as a/an Name of Employer No. 1 (if applicable) Name of Employer No. 2 (if applicable) . . . . since (Company Name) (mm/dd/yyyy) b. c. d. Self-employed as a/an Retired from Unemployed since (mm/dd/yyyy) . 10. My current individual annual income is: $__________________________________________. 11. Federal income tax information. I have filed a Federal tax return for each of the three most recent tax years. I have attached the required photocopy or transcript of my Federal tax return for only the most recent tax year. My total income (adjusted gross income on IRS Form 1040EZ) as reported on my Federal tax returns for the most recent three years was: Tax Year (most recent) $ Total Income (2nd most recent) $ (3rd most recent) $ (Optional) I have attached photocopies or transcripts of my Federal tax returns for my second and third most recent tax years. 12. My assets (complete only if necessary). a. Enter the balance of all cash, savings, and checking accounts. $___________________________. b. Enter the net cash value of real-estate holdings. (Net means assessed value minus mortgage debt.) $___________________________. c. Enter the cash value of all stocks, bonds, certificates of deposit, and other assets not listed on line a or b. $___________________________. d. Add together Lines a, b, and c and enter the number here. $___________________________. Form I-864A (03/22/13) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Sponsor's Promise. 13. I, THE SPONSOR, (Print Name) For Government Use Only in consideration of the household member's promise to support the following intending immigrant(s) 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 immigrant(s) (see Step-by-Step instructions). Name a. b. c. d. e. (Indicate Number) named intending Date of Birth (mm/dd/yyyy) A-number (if any) U.S. Social Security Number (if any) 14. (Sponsor's Signature) (Date--mm/dd/yyyy) Part 3. Household Member's Promise. 15. 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 (Number from line 13) named intending immigrant(s): a. Promise to provide any and all financial support necessary to assist the sponsor in maintaining the sponsored immigrant(s) at or above the minimum income provided for in section 213A(a)(1)(A) of the Act (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 immigrant(s), 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 benefit; c. Certify under penalty under the laws of the United States that all the information provided on this form is true and correct to the best of my knowledge and belief and 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, 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 section 213A(s)(1)(A) of the Act (not less than 125 percent of the Federal poverty line) during the period which the affidavit of support is enforceable. e. 16. (Household Member's Signature) (Date--mm/dd/yyyy) Form I-864A (03/22/13) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com 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.
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