Page 2,
Part 4. Your (the
Household Member’s) Federal Income Tax Information and
Assets
|
[Page
2]
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
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 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:
2.a.
Most Recent
Tax
Year
Total
Income $
2.b.
2nd Most Recent
Tax
Year
Total
Income $
2.c.
3rd Most Recent
Tax
Year
Total
Income $
My
assets (complete only if necessary).
3.a.
Enter the balance of all cash, savings, and checking accounts. $
3.b.
Enter the net cash value of real-estate holdings. (Net value
means assessed value minus mortgage debt.) $
3.c.
Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item
Numbers 3.a.
or 3.b.
$
3.d.
Add together Item
Numbers 3.a.,
3.b.,
and 3.c.
and enter the number here. $
|
[Page
2]
Part
4. Your (the Household Member's) Federal Income Tax Information
and Assets
1.
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.
[delete]
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:
2.
Most Recent
Tax
Year
Total
Income $
2nd
Most Recent
Tax
Year
Total
Income $
3rd
Most Recent
Tax
Year
Total
Income $
My
assets (complete only if necessary).
3.
Enter the balance of all cash, savings, and checking accounts. $
4.
Enter the net cash value of real-estate holdings. (Net value
means assessed value minus mortgage debt.) $
5.
Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item Numbers 3.
- 4. $
6.
Add together Item Numbers 3. - 5.
and enter the number here. $
|
Pages 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)
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-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 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]
1.
Intending
Immigrant Number 1
Family
Name
(Last Name)
Given
Name
(First Name)
Middle
Name
(if
applicable)
Date
of
Birth (mm/dd/yyyy)
Alien
Registration
Number (A-Number, if any)
[delete]
USCIS
Online
Account Number (if any)
2.
Intending
Immigrant Number 2
Family
Name
(Last Name)
Given
Name
(First Name)
Middle
Name
(if
applicable)
Date
of
Birth (mm/dd/yyyy)
Alien
Registration
Number (A-Number, if any)
[delete]
USCIS
Online
Account Number (if any)
3.
Intending
Immigrant Number 3
Family
Name
(Last Name)
Given
Name
(First Name)
Middle
Name
(if
applicable)
Date
of
Birth (mm/dd/yyyy)
Alien
Registration
Number (A-Number, if any)
[delete]
USCIS
Online
Account Number (if any)
4.
Intending
Immigrant Number 4
Family
Name
(Last Name)
Given
Name
(First Name)
Middle
Name
(if
applicable)
Date
of
Birth (mm/dd/yyyy)
Alien
Registration
Number (A-Number, if any)
[delete]
USCIS
Online
Account Number (if any)
[delete]
Sponsor's
Statement
NOTE:
Select the box for either Item
Number 5.a.
or
5.b.
If
applicable, select the box for Item
Number 6.
5.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]
5.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.
6.
[
] 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
7.
Sponsor's
Daytime Telephone Number
8.
Sponsor's
Mobile Telephone Number (if any)
9.
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
10.
Sponsor's
Signature
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.
|
Pages 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.
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]
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 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.
|
[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.
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]
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 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.
Your
(the Household Member's) Printed Name
7.
Your
(the Household Member's) Signature
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.
|
Pages 5-6,
Part 7.
Interpreter’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)
|
[Page
5]
Part
7.
Interpreter's
Contact Information, Certification, and Signature
[delete]
Interpreter's
Full
Name
1.
Interpreter's
Family Name (Last Name)
Interpreter's
Given
Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
[Page
6]
[delete]
Interpreter's
Contact
Information
3.
Interpreter's
Daytime Telephone Number
4.
Interpreter’s
Mobile Telephone Number (if any)
5.
Interpreter's
Email Address (if any)
Interpreter's
Certification
I
certify, under penalty of perjury, that
I am
fluent in English and [Fillable Field], and
I
have interpreted
every question on the contract and instructions and interpreted
the sponsor’s or
household member’s
answers to
the
questions in that language and the sponsor
or household member informed me that he or she understood
every
instruction, question, and answer on the contract.
[delete]
6.
Interpreter's
Signature
Date
of Signature (mm/dd/yyyy)
|
Pages 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)
|
[Page
6]
Part
8. Contact Information, Declaration, and Signature of the Person
Preparing this Contract, if Other Than the Sponsor or Household
Member
[delete]
Preparer's
Full
Name
1.
Preparer's
Family Name (Last Name)
Preparer's
Given
Name (First Name)
2.
Preparer's Business or Organization Name (if any)
[delete]
Preparer's
Contact
Information
3.
Preparer's
Daytime Telephone Number
4.
Preparer’s
Mobile Telephone Number (if any)
5.
Preparer's
Email Address (if any)
[Page
7]
[delete]
Preparer's
Certification
and
Signature
I
certify,
under penalty of perjury, that I prepared this contract
for the
sponsor and household member at
their request and with express consent and that all of the
responses and information
contained in
and
submitted with the
contract
are
complete,
true, and correct and
reflects
only
information provided by
the sponsor and household member.
The sponsor and household member reviewed the responses and
information and
informed me that they understand the responses and information in
or submitted with the contract.
[delete]
6.
Preparer's
Signature
Date
of
Signature (mm/dd/yyyy)
|