Page 2-4,
Part 5. Sponsor’s
Promise, Statement, Contact Information, Declaration,
Certification, and Signature
|
[Page 2]
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, [fillable box
(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.
[fillable box (Indicate Number)]
[Page 3]
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)
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)
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)
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)
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)
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, I and have read and understand every question
and instruction on this contract and my answer to every question.
[Page 4]
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
[fillable field], a language in which I am fluent, and I
understood everything.
27. [ ] At my request,
the preparer named in Part 8., [Fillable Filed], 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.
|
[Page 2]
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.
I, THE SPONSOR, [fillable box
(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.
[fillable box (indicate number of intending immigrants)]
[Page 3]
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)
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)
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)
15. USCIS Online Account
Number (if any)
Intending Immigrant Number 4
Name
6.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)
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)
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.
[Page 4]
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 [fillable field], a language in
which I am fluent, and I understood everything.
27. [ ] At my request,
the preparer named in Part 7.,
[Fillable Filed], prepared this contract for me based only
upon information I provided or authorized to be provided.
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
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.
law.
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.
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.
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.
Sponsor's
Signature
31.a. Sponsor's Signature
31.b. Date of Signature
(mm/dd/yyyy)
Subscribed
and sworn to (or affirmed) before me this [fillable field] day of
[fillable field] (Month), [fillable field] (Year) at [fillable
field].
My commission
expires on (mm/dd/yyyy)__________
Signature of
Notary Public
Notary
Public Stamp
[space
for 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.
Part 6.
Sponsor’s Interpreter's Contact Information, Certification,
and Signature
Provide the
following information about the interpreter if you used one.
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)
Interpreter's
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
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)
Sponsor’s
Interpreter's Certification
I certify,
under penalty of perjury, that the following is true and correct:
I am fluent in
English and [Fillable Field], 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
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
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
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
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)
[Page 7]
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.
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.
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)
|
Page 4-5,
Part 6. Your (the
Household Member’s) Promise, Statement, Contact Information,
Declaration, Certification, and Signature
|
[Page 4]
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.
[New]
I, THE HOUSEHOLD MEMBER,
[fillable box (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. [fillable box] (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.
[Page 5]
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.
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 7. read to me every question and instruction
on this contract and my answer to every question in [Fillable
Field], a language in which I am fluent, and I understood
everything.
2. [ ] At my request,
the preparer named in Part 8., [Fillable Filed], prepared
this contract for me based only upon 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 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.
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.
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.
What
If I Do Not Fulfill My Obligations?
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
means-tested 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.
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;
B.
Has worked, or can receive credit for, 40 quarters of coverage
under the Social Security Act;
C.
No longer has lawful permanent resident status and has departed
the United States;
D.
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
E.
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,
[fillable box (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:
[fillable box] (Print number of
intending immigrants noted in Part 5. Sponsor's Contract,
Statement, Contact Information,
Certification, and Signature.)
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;
B.
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;
C.
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;
[deleted]
D.
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;
E.
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;
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;
G.
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;
H.
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;
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;
I.
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
J.
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 [Fillable Field], a language in
which I am fluent, and I understood everything.
2. [ ] At my request,
the preparer named in Part 10.,
[Fillable Filed], prepared this contract for me based only upon
information I provided or authorized to be
provided.
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)
[deleted]
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)
Subscribed
and sworn to (or affirmed) before me this [fillable field] day of
[fillable field] (Month), [fillable field] (Year) at [fillable
field].
My commission
expires on (mm/dd/yyyy)__________
Signature of
Notary Public
Notary
Public Stamp
[space
for 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.
|
Page 5-6,
Part 7.
Interperter’s Contact Information, Certification, and
Signature
|
[Page 5]
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)
[Page 6]
Interpreter's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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
I certify, under penalty of perjury,
that:
I am fluent in English and [Fillable
Field], 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)
|
Part 9.
Household Member’s 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)
Interpreter's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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
I certify, under penalty of perjury,
that the following is true and correct:
I am fluent in English and [Fillable
Field], 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.
Interpreter's Signature
7.a. Interpreter's Signature
7.b. Date of Signature (mm/dd/yyyy)
|
Page 6-7,
Part 8. Contact
Information, Declaration, and Signature of the Person Preparing
this Contract, if Other Than the Sponsor or Household Member
|
[Page 6]
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)
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
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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)
[Page 7]
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 and sponsor 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.
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)
|
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
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)
2. Preparer's Business or
Organization Name (if any)
Preparer's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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)
[Page 7]
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
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 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.
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)
|