Contract Between Sponsor and Household Member Department of Homeland Security U.S. Citizenship and Immigration Services For Government Use Only This Form I-864A relates to a household member who: IS the intending immigrant IS NOT the intending immigrant Reviewed By: Location: Date (mm/dd/yyyy): USCIS Form I-864A OMB No. 1615-0075 Expires 07/31/2017 START HERE - Type or print in black ink. Part 1. Information About You (the Household Member) Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Physical Address 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.f. Province 4.e. ZIP Code Mailing Address 2.a. In Care Of Name 4.g. Postal Code 4.h. Country 2.b. Street Number and Name 2.c. Apt. Ste. Flr. Other Information 5. Date of Birth (mm/dd/yyyy) 2.d. City or Town 2.e. State 2.g. Province 2.f. ZIP Code Place of Birth 6.a. City or Town 6.b. State or Province 2.h. Postal Code 2.i. Country 6.c. Country 3. Is your current mailing address the same as your physical address? Yes No 7. U.S. Social Security Number (if any) If you answered "No" to Item Number 3., provide your physical address. 8. USCIS ELIS Account Number (if any) Form I-864A 07/02/15 N Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Your (the Household Member's) Relationship to the Sponsor Select Item Number 1.a., 1.b., or 1.c. 1.a. 1.b. 1.c. I am the intending immigrant and also the sponsor's spouse. I am the intending immigrant and also a member of the sponsor's household. I am not the intending immigrant. I am the sponsor's household member. I am related to the sponsor as his/her: Spouse Son or daughter (at least 18 years of age) Parent Brother or sister Other dependent (Specify) Part 4. Your (the Household Member's) Federal Income Tax Information and Assets 1. I have filed a Federal income tax return for each of the three most recent tax years. I have attached the required photocopy or transcript of my Federal income tax return for only the most recent tax year. 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 2.a. Most Recent 2.b. 2nd Most Recent 2.c. 3rd Most Recent $ $ $ Total Income (Optional) I have attached photocopies or transcripts of my Federal income tax returns for my second and third most recent tax years. My assets (complete only if necessary). 3.a. Enter the balance of all cash, savings, and checking accounts. Part 3. Your (the Household Member's) Employment and Income I am currently: 1.a. Employed as a/an $ 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. $ 1.a.1. Name of Employer Number 1 (if applicable) 1.a.2. Name of Employer Number 2 (if applicable) 3.d. Add together Item Numbers 3.a., 3.b., and 3.c. and enter the number here. $ 1.b. Self employed as a/an 1.c. Retired from (Company Name) Since 1.d. (mm/dd/yyyy) Unemployed since (mm/dd/yyyy) My current individual annual income is: $ 2. Form I-864A 07/02/15 N Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 5. Sponsor's Promise, Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-864A Instructions before completing this part. I, THE SPONSOR, 9. U.S. Social Security Number (if any) 10. USCIS ELIS Account Number (if any) Intending Immigrant Number 3: Name , (Print Name) in consideration of the household member's promise to support the following intending immigrant(s) and to be jointly and severally liable for any obligations I incur under the affidavit of support, promise to complete and file an affidavit of support on behalf of the following named intending immigrant(s). 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. 13. Date of Birth (mm/dd/yyyy) (Indicate Number) Intending Immigrant Number 1: Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. 3. Date of Birth (mm/dd/yyyy) 15. 14. A-Number (if any) AU.S. Social Security Number (if any) USCIS ELIS 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. 18. Date of Birth (mm/dd/yyyy) A19. U.S. Social Security Number (if any) 20. USCIS ELIS Account Number (if any) Intending Immigrant Number 5: Name (mm/dd/yyyy) 21.a. Family Name (Last Name) 21.b. Given Name (First Name) 21.c. Middle Name A-Number (if any) AU.S. Social Security Number (if any) 4. 5. USCIS ELIS Account Number (if any) A-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. 8. Date of Birth A-Number (if any) A- Form I-864A 07/02/15 N Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 5. Sponsor's Promise, Statement, Contact Information, Certification, and Signature (continued) 22. 23. Date of Birth A-Number A24. U.S. Social Security Number (if any) 25. USCIS ELIS Account Number (if any) (mm/dd/yyyy) Sponsor's Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS or the Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS or the Department of State 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 Department of State record to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I certify, under penalty of perjury, that the information in my contract and any document submitted with my contract were provided by me and are complete, true, and correct. 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 have read and understand every question and instruction on this contract, as well as my answer to every question. The interpreter named in Part 7. has also read to me every question