Get USCIS I-864A 2021-2024

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 03/31/2020 For Government Use Only This Form I-864A relates to a household member who IS the intending immigrant IS NOT the intending To be completed by an attorney or accredited representative if any. Sponsor s Promise Statement Contact Information Declaration Certification and Signature Self employed as a/an NOTE Read the Penalties section of the Form I-864A Instructions before completing this part. Provide your Form I-864A 03/06/18 6. c. Country U.S. Social Security Number if any Page 1 of 8 NOTE You MUST attach a photocopy or transcript of your Federal income tax return for only the most recent tax year. Consideration where the household member is also the sponsored immigrant I understand that if I am 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 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 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. B. I am an attorney or accredited representative and my representation of the sponsor and household member in this case extends does not extend beyond the preparation of this contract. NOTE If you are an attorney or accredited completed Form G-28 Notice of Entry of Appearance as Attorney or Accredited Geographical Confines of the United States with this Preparer s Certification By my signature I certify under penalty of perjury that I 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 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. 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 7. b. I am an attorney or accredited representative and my representation of the sponsor and household member in this case extends does not extend beyond the preparation of this contract. NOTE If you are an attorney or accredited completed Form G-28 Notice of Entry of Appearance as Attorney or Accredited Geographical Confines of the United States with this Preparer s Certification By my signature I certify under penalty of perjury that I 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 all of this information is complete true and correct. 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 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. C. 1. a. spouse. 1. b. 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 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 2.