Form I-864A Contract Between Sponsor and Household Member

Affidavit of Support Under Section 213A of the Act

I864A-005-FRM-Rev-30Day-Rev-06222020

Affidavit of Support Under Section 213A of the Act

OMB: 1615-0075

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1615-0075 can be found here:

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Contract Between Sponsor and Household Member
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-864A
OMB No. 1615-0075
Expires 10/31/2021

For Government Use Only
This Form I-864A relates to a household member who:

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IS the intending
immigrant

IS NOT the
intending
immigrant

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 or
G-28I is attached.

Reviewed By:
Location:

Date (mm/dd/yyyy):

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You (the Household
Member)
Full Name

Physical Address

4.a. Street Number
and Name

4.b.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Apt.

Ste.

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

1.c. Middle Name

4.f.

Mailing Address

(USPS ZIP Code Lookup)

4.e. ZIP Code

Province

4.g. Postal Code

2.a. In Care Of Name

4.h. Country

2.b. Street Number
and Name

Other Information

2.c.

Apt.

Flr.

Ste.

Flr.

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

Date of Birth (mm/dd/yyyy)

Place of Birth
2.f.

ZIP Code

2.g. Province

6.a. City or Town

6.b. State or Province

2.h. Postal Code
2.i.

Country

6.c. Country

Is your current mailing address the same as your physical
address?
Yes
No

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

Form I-864A 10/15/19

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

USCIS Online Account Number (if any)
►

Page 1 of 13

Part 1. Information About You (the Household
Member) (continued)

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

Household Member's Bank Account Information

I am currently:

9.a. Account Type

Employed as a/an

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Checking

Savings

Name of Employer Number 1

Family Name
(Last Name)
Given Name
(First Name)

Name of Employer Number 2 (if applicable)

Middle Name

Self employed as a/an

Retired from (Company Name)

9.b. Account Holder's Name

9.c. Name(s) of Joint Account Holders, if any
Family Name
(Last Name)
Given Name
(First Name)

Since (mm/dd/yyyy)

Middle Name

Unemployed since (mm/dd/yyyy)

My current individual annual income is:
$

9.d. Institution Name

9.e. Account Number

Federal Income Tax Information

9.f.

Routing Number

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

8.a. Have you filed a Federal income tax return for each of the
three most recent tax years?
Yes
No
NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
tax year.

8.b.

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

(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
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:
Tax Year

Total Income

9.a. Most Recent

9.b. 2nd Most Recent

9.c. 3rd Most Recent

Son or daughter (at least 18 years of age)
Parent

Credit Report Information (Optional)

Brother or sister

10.

I have attached a copy of a recent U.S. credit report.

Other dependent (Specify)

Form I-864A 10/15/19

Page 2 of 13

Part 4. Use of Your (the Household Member's)
Assets to Supplement Sponsor's Income
(Optional)

Intending Immigrant Number 2

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.)

Name

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$

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

6.c. Middle Name

Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not already included in Item
Number 1. or Item Number 2.
$

USCIS Online Account Number (if any)
►

Add together Item Numbers 1.-3. and enter the number
here.
TOTAL $

Date of Birth (mm/dd/yyyy)

Alien Registration Number (A-Number, if any)
► A-

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

10.

Part 5. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-864A
Instructions before completing this part.

USCIS Online Account Number (if any)
►

Intending Immigrant Number 3

Name

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 of intending immigrants)

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)
►

Intending Immigrant Number 1
15.

Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Intending Immigrant Number 4
Name

1.c. Middle Name
2.

Date of Birth (mm/dd/yyyy)

Alien Registration Number (A-Number, if any)
► A-

USCIS Online Account Number (if any)
►

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

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-

Form I-864A 10/15/19

Page 3 of 13

Sponsor's Contact Information

Part 5. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)
19.

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

20.

Intending Immigrant Number 5

Sponsor's Mobile Telephone Number (if any)

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.

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)

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. law.

►

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.

26.b.

The interpreter named in Part 6. read to me every
question and the Sponsor Statement and Certification
instruction on this contract and my answer to every
question in
,
a language in which I am fluent, and I understood
everything.
At my request, the preparer named in Part 7.,
,
prepared this contract for me based only upon
information I provided or authorized to be provided.

Form I-864A 10/15/19

Sponsor's Email Address (if any)

Sponsor's Certification

21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)

27.

29.

30.

►

25.

Sponsor's Daytime Telephone Number

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USCIS Online Account Number (if any)

Name

28.

I authorize agencies and entities that administer or oversee
means-tested public benefits, and any agency or entity that is
authorized to act on its behalf, to disclose information to the
U.S. Department of Homeland Security (DHS) and DOS, for
the purpose of administration of federal laws regarding my
obligations as a sponsor, as agreed to in the Form I-864 I
executed on behalf of the above named intending immigrants
and in this Form I-864A, and only as permitted by law. If any
of the above named intending immigrants that I sponsored on
the Form I-864 I executed and on this Form I-864A applies for
a means-tested public benefit, including Medicaid, the
Children's Health Insurance Program, Temporary Assistance to
Needy Families, or the Supplemental Nutrition Assistance
Program, or any other Federal or State public benefit subject to
deeming of my income and/or assets/resources or for which I
could be liable for reimbursement, I specifically authorize the
agencies and entities that administer or oversee means-tested
public benefits, and any agency or entity that is authorized to
act on its behalf, to disclose my name, Social Security number,
date of birth, information about the agency's deeming of my
income and/or assets/resources, and any reimbursement
obligations to DHS and DOS. This consent is valid for the
entire period of enforceability of my obligations as a sponsor.
I understand that the information that agencies and entities that
administer or oversee means-tested public benefits, and any
agency or entity that is authorized to act on its behalf, disclose
to DHS and DOS is for official use only to administer federal
laws regarding my support obligations as a sponsor, and that
DHS and DOS may disclose my information only as authorized
by law.
Page 4 of 13

Part 5. Sponsor's Contract, Statement, Contact
Information, Certification, and Signature
(continued)

Part 6. Sponsor's Interpreter's Contact
Information, Certification, and Signature

I authorize the Social Security Administration (SSA) to disclose
information to DHS and DOS, for the purpose of administration
of federal laws regarding my obligations as a sponsor, as agreed
to in the Form I-864 I executed on behalf of the above named
intending immigrants and in this Form I-864A and only as
permitted by law. If any of the above named intending
immigrants for whom I have an obligation as a sponsor based
on the Form I-864 I executed and this Form I-864A applies for
Supplemental Security Income payments, I specifically
authorize SSA to disclose my name, Social Security number,
date of birth, the deeming of my income and/or assets/resources,
and my reimbursement obligations to DHS and DOS. This
consent is valid for the entire period of enforceability of my
obligations as a sponsor. I understand that the information SSA
discloses to DHS and DOS is for official use for the purpose of
administration of federal laws regarding my obligation as a
sponsor and that DHS and DOS may disclose my information as
authorized by law.

Provide the following information about the interpreter if you
used one.

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Interpreter's Full Name

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

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

Interpreter's Mailing Address

3.a. Street Number and Name

3.b.

I certify, under penalty of perjury, that I provided or authorized
to have provided all of the information in my contract, I
understand all of the information contained in, and submitted
with, my contract, and that all of this information is complete,
true, and correct.

Interpreter's Business or Organization Name (if any)

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Sponsor's Signature

3.e. ZIP Code

Province

3.g. Postal Code

31.a. Sponsor's Signature

3.h. Country

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

Interpreter's Contact Information

Subscribed and sworn to (or affirmed) before me this
day of
(Month),

(Year) at

Interpreter's Daytime Telephone Number

Interpreter's Mobile Telephone Number (if any)

Interpreter's Email Address (if any)

My commission expires on (mm/dd/yyyy)
Signature of Notary Public

Notary Public Stamp

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 reject or deny your contract.
Form I-864A 10/15/19

Page 5 of 13

Preparer's Mailing Address

Part 6. Sponsor's Interpreter's Contact
Information, Certification, and Signature
(continued)

3.a. Street Number and Name

Interpreter's Certification

3.b.

I certify, under penalty of perjury, that the following is true and
correct:

3.c. City or Town

I am fluent in English and

3.d. State

Apt.

Ste.

Flr.

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,

which is the same language specified in Part 5., Item Number
26.b. and I have read to this sponsor in the identified language
every question and instruction on this contract and his or her
answer to every question. The sponsor informed me that he or
she understands every instruction, question, and answer in the
Sponsor's contract, including the Sponsor's Certification, and
has verified the accuracy of every answer.

Interpreter's Signature
7.a. Interpreter's Signature

3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information

Preparer's Daytime Telephone Number

Preparer's Mobile Telephone Number (if any)

Preparer's Email Address (if any)

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

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
for the Sponsor, if Other Than the Sponsor or
Household Member
Provide the following information about the preparer.

Preparer's Statement

7.a.

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 and
household member's consent.

7.b.

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

Preparer's Full Name

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

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

Preparer's Business or Organization Name (if any)

Form I-864A 10/15/19

NOTE: If you are an attorney or accredited
representative, you may need 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.

Page 6 of 13

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
for the Sponsor, if Other Than the Sponsor or
Household Member (continued)

Under this contract, you agree that, in deciding whether the
intending immigrant can establish that he or she is not
inadmissible to the United States as an individual likely at any
time to become a public charge, the U.S. Government can
consider your income and assets as available for the support of
the intending immigrant. The sponsored immigrant, any entity
that provides a means-tested public benefit to the sponsored
immigrant, and the appropriate government agency are third
party beneficiaries of this contract and may bring an action to
enforce this contract.

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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 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)

Part 8. Your (the Household Member's)
Contract, Statement, Contact Information,
Certification, and Signature

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

Household Member's Contract

Please note that, by signing this Form I-864A, you agree to
assume certain obligations under the Immigration and
Nationality Act (INA) and other Federal laws. The following
paragraphs describe those obligations. Please read the
following information carefully before you sign Form I-864A.
If you do not understand the obligations, you may wish to
consult an attorney or accredited representative.
What is the Legal Effect of My Signing Form I-864A?
If you sign Form I-864A on behalf of any individual who is
applying for an immigrant visa or for adjustment of status to
become a lawful permanent resident (the intending immigrant),
and that intending immigrant submits Form I-864A to the U.S.
Government with his or her application for an immigrant visa or
adjustment of status, under INA section 213A, these actions
create a contract between you and the sponsor. The intending
immigrant becoming a lawful permanent resident (sponsored
immigrant) is the consideration for the contract.

Form I-864A 10/15/19

What If I Choose Not to Sign Form I-864A?

The U.S. Government cannot make you sign Form 1-864A if
you do not want to do so. But if you do not sign Form I-864A,
the intending immigrant may not become a lawful permanent
resident in the United States.
What Does Signing Form I-864A Require Me To Do?
If an intending immigrant becomes a lawful permanent resident
of the United States (sponsored immigrant) based on a Form
I-864A that you have signed, then, until your obligations under
Form I-864A terminate, you must provide the sponsor any
support necessary to maintain the sponsored immigrant him or
her at an income that is at least 125 percent of the Federal
Poverty Guidelines based on the sponsor's household size (100
percent if the sponsor you are signing Form I-864A with is the
petitioning sponsor and is on active duty in the U.S. Armed
Forces, other than active duty for training, and the intending
immigrant is the sponsor's husband, wife, or unmarried child
under 21 years of age).
What Other Consequences Are There?

If an intending immigrant becomes a lawful permanent resident
of the United States based on a Form I-864A that you have
signed, then, until your obligations under Form I-864A
terminate, the U.S. Government may consider (deem) your
income and assets as available to that individual, in determining
whether he or she is eligible for certain Federal means-tested
public benefits and also for state or local means-tested public
benefits, if the state or local government's rules provide for
consideration (deeming) of your income and assets as available
to the individual.
This provision does not apply to public benefits specified in
section 403(c) of the Welfare Reform Act such as emergency
Medicaid, short-term, non-cash emergency relief; services
provided under the National School Lunch and Child Nutrition
Acts; immunizations and testing and treatment for
communicable diseases; and means-tested public benefits under
the Elementary and Secondary Education Act.

Page 7 of 13

Part 8. Your (the Household Member's)
Contract, Statement, Contact Information,
Certification, and Signature (continued)

in consideration of the sponsor's promise to complete and file an
affidavit of support on behalf of the above named intending
immigrants:

What If I Do Not Fulfill My Obligations?

(Print number of intending immigrants noted in Part 5.
Sponsor's Contract, Statement, Contact Information,
Certification, and Signature.)

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If you do not provide sufficient support to the sponsor to enable
the sponsor to maintain the sponsored immigrant(s) listed on
this Form I-864A, the sponsor can sue you to enforce this
contract. Additionally, the sponsored immigrants listed on this
Form I-864A, as third party beneficiaries to this contract, can
sue you for this support.

If a Federal, state, local, or private entity provided any meanstested public benefits to the sponsored immigrants listed on this
Form I-864A, you are responsible for reimbursing the agency
for the amount of the benefits they provided, upon request. If
you do not reimburse the agency upon request, that entity, or the
appropriate government agency, as a third-party beneficiary of
this contract, can sue you for the amount of means-tested public
benefits paid.
If you are sued, and the court enters a judgment against you, the
individual or agency that sued you may use any legally
permitted procedures for enforcing or collecting the judgment.
You may also be required to pay the costs of collection,
including attorney fees.

Your (the Household Member's) Certification

Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that I may be
required to 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 any 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 individuals where necessary for the
administration and enforcement of U.S. law.
I certify, under penalty of perjury, that:
A.

I provided or authorized to have provided all of the
information in my contract, I understand all of the
information contained in, and submitted with, my
contract, and that all of this information is complete,
true, and correct;

I 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, or 100 percent if the
sponsor you are signing Form I-864A with is the
petitioning sponsor and is on active duty in the U.S.
Armed Forces, other than active duty for training, and
the intending immigrant is the sponsor's husband, wife,
or unmarried child under 21 years of age) during the
period in which the affidavit of support is enforceable;

I agree to be jointly and severally liable for payment
of any and all obligations owed by the sponsor
under the Form I-864 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;

I agree to submit to the personal jurisdiction of any
Federal state, or local court that has subject matter
jurisdiction of a lawsuit against me to enforce my
obligations under this Form I-864A;

Each of the Federal income tax returns submitted in
support of this contract are true copies, or are
unaltered tax transcripts, of the tax returns I filed
with the IRS;

When Will These Obligations End?

Your obligations under a Form I-864A that you signed will end
if sponsored immigrant(s) listed on this Form I-864A:
A.

Becomes a U.S. citizen;

Has worked, or can receive credit for, 40 quarters of
coverage under the Social Security Act;

No longer has lawful permanent resident status and
has departed the United States;

Is subject to removal, but applies for and obtains, in
removal proceedings, a new grant of adjustment of
status, based on a new affidavit of support, if one is
required; or

Dies.

NOTE: Divorce does not terminate your obligations under
Form I-864A.
Your obligations under a Form I-864A that you signed also end
if you die. Therefore, if you die, your estate is not required to
take responsibility for the individual's support after your death.
However, your estate may owe any means-tested public benefits
that the intending immigrant received before you died.
I, THE HOUSEHOLD MEMBER,

,
(Print Name)

Form I-864A 10/15/19

Page 8 of 13

I understand that the information that agencies and
entities that administer or oversee means-tested public
benefits, and any agency or entity that is authorized to
act on its behalf, disclose to DHS and State is for official
use only to administer federal laws regarding my
support obligations as a household member who has
signed and submitted this Form I-864A, and that DHS
and State may disclose my information only as
authorized by law;

Part 8. Your (the Household Member's)
Contract, Statement, Contact Information,
Certification, and Signature (continued)
F.

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,
or 100 percent if the sponsor you are signing Form
I-864A with is the petitioning sponsor and is on
active duty in the U.S. Armed Forces, other than
active duty for training, and the intending
immigrant is the sponsor's husband, wife, or
unmarried child under 21 years of age) during the
period which the affidavit of support is enforceable;

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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;
I authorize agencies and entities that administer or
oversee means-tested public benefits, and any agency or
entity that is authorized to act on its behalf, to disclose
information to DHS and DOS, for the purpose of
administration of federal laws regarding my obligations
as a household member who has signed and submitted
this Form I-864A, as agreed to in this Form I-864A and
only as permitted by law. If any alien that I have an
obligation for as agreed to in this Form I-864A applies
for a means-tested public benefit, including Medicaid,
the Children's Health Insurance Program, Temporary
Assistance to Needy Families, or the Supplemental
Nutrition Assistance Program, or any other Federal or
State public benefit subject to deeming of my income
and/or assets/resources or for which I could be liable for
reimbursement, I specifically authorize the agencies and
entities that administer or oversee means-tested public
benefits, and any agency or entity that is authorized to
act on its behalf, to disclose my name, Social Security
number, date of birth, information about the agency's
deeming of my income and/or assets/resources, and any
reimbursement obligations to DHS and State. This
consent is valid for the entire period of enforceability of
my obligations as a household member.

Form I-864A 10/15/19

I authorize the Social Security Administration
(SSA) to disclose information to DHS and State, for
the purpose of administration of federal laws
regarding my obligations as a household member
who has signed and submitted this Form I-864A, as
agreed to in this Form I-864A and only as permitted
by law. If any alien that I have an obligation for as
agreed to in this Form I-864At applies for
Supplemental Security Income payments, I
specifically authorize SSA to disclose my name,
Social Security number, date of birth, the deeming
of my income and/or assets/resources, and my
reimbursement obligations to DHS and State. This
consent is valid for the entire period of
enforceability of my obligations as a household
member. I understand that the information SSA
discloses to DHS and State is for official use for the
purpose of administration of federal laws regarding
my obligation as a sponsor and that DHS and State
may disclose my information as authorized by law;
and

I acknowledge that if I fail to meet the obligations
and requirements of this contract, I may be found
ineligible to be a sponsor in the future.

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
and understand every question and instruction on this
contract and my answer to every question.

1.b.

The interpreter named in Part 9. 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.

At my request, the preparer named in Part 10.,
,
prepared this contract for me based only upon
information I provided or authorized to be provided.

Page 9 of 13

Part 9. Household Member's Interpreter's Contact
Information, Certification, and Signature

Part 8. Your (the Household Member's)
Contract, Statement, Contact Information,
Certification, and Signature (continued)

Provide the following information about the interpreter.

Your (the Household Member's) Contact
Information
3.

Interpreter's Full Name

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

Your (the Household Member's) Daytime Telephone
Number

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

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

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

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3.a. Street Number and Name

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

3.b.

Apt.

3.d. State

6.c. Date of Signature (mm/dd/yyyy)

3.f.

Subscribed and sworn to (or affirmed) before me this

3.g. Postal Code

My commission expires on (mm/dd/yyyy)
Signature of Notary Public

3.e. ZIP Code

Province

3.h. Country

day of

(Year) at

Flr.

3.c. City or Town

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

(Month),

Ste.

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

Interpreter's Mobile Telephone Number (if any)

Interpreter's Email Address (if any)

Notary Public Stamp

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 reject or deny
your contract.

Form I-864A 10/15/19

Page 10 of 13

Preparer's Mailing Address

Part 9. Household Member's Interpreter's Contact
Information, Certification, and Signature
(continued)

3.a. Street Number and Name

Interpreter's Certification

3.b.

I certify, under penalty of perjury, that the following is true and
correct:

3.c. City or Town

I am fluent in English and
,
which is the same language specified in Part 5., Item Number
26.b. or Part 8., Item Number 1.b., and I have read to this
household member in the identified language every question
and instruction on this contract and his or her answer to every
question in the household member's contract. The household
member informed me that he or she understands every
instruction, question, and answer on the contract, including the
Household Member's Certification, and has verified the
accuracy of every answer.

3.d. State

Interpreter's Signature

Preparer's Daytime Telephone Number

Preparer's Mobile Telephone Number (if any)

Preparer's Email Address (if any)

Apt.

Ste.

Flr.

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3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information

7.a. Interpreter's Signature

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

Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
for the Household Member, if Other Than the
Sponsor or Household Member

Preparer's Statement

7.a.

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.

7.b.

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

Provide the following information about the preparer.

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

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

Preparer's Business or Organization Name (if any)

Form I-864A 10/15/19

Page 11 of 13

Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Contract,
for the Household Member, if Other Than the
Sponsor or Household Member (continued)

DRAFT
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Preparer's Certification

Preparer's Signature
8.a. Preparer's Signature

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

Form I-864A 10/15/19

Page 12 of 13

5.a. Page Number

Part 11. 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.

5.b. Part Number

5.c. Item Number

5.d.

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1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

A-Number (if any)

► A-

6.a. Page Number

3.a. Page Number

3.b. Part Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number
4.a. Page Number

4.b. Part Number

4.c. Item Number
7.d.

4.d.

Form I-864A 10/15/19

Page 13 of 13

File Type	application/pdf
File Title	Form I-864A, Contract Between Sponsor and Household Member
Subject	Contract Between Sponsor and Household Member
Author	USCIS
File Modified	2020-06-22
File Created	2020-06-22