USCIS Form I-864A "Contract Between Sponsor and Household Member"

What Is Form I-864A?

Form I-864A, Contract Between Sponsor and Household Member, is a form that has to be filled in by a sponsor and a household member to prove their income. Such confirmation is needed for their familiar intending immigrant - an individual that plans to obtain a permanent U.S. residence.

Alternate Name:

  • USCIS Form I-864A.

A sponsor, in this case, is a person who has submitted the visa petition for this immigrant and declares their agreement to provide them financial assistance. If their earnings are insufficient, they should add a household member, the presence of extra earnings of which are disclosed with the use of Form I-864A.

This form was released by the U.S. Citizenship and Immigration Services (USCIS) and the latest version was issued on October 15, 2019. A fillable I-864A PDF is available for download below.

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Form I-864A Instructions

The I-864A Form has to be filled in by using black ink only. Official guidelines can be found in the USCIS-issued I-864A instructions, but a short summary may be found below:

  1. The filer has to enter their personal information (their full name, date of birth, place of birth, Social Security Number (SSN), and mailing address) in Part 1. A physical address should be provided if it is different from the indicated.
  2. The filer has to specify their relationship to the sponsor in Part 2.
  3. Employment details and information about the filer's current annual income should be entered in Part 3.
  4. The filer must provide information about their federal income tax return in Part 4. Specify the size of the total income for these periods, and enter data regarding assets if necessary.
  5. Part 5 should be filled in by a sponsor. They have to enter their name, provide personal information about intending immigrants being sponsored. The filer should indicate if they have requested the services of an interpreter when filling out the form, enter their contact details, and has to sign this section.
  6. Part 6 must be filled in by a household member. They have to provide their name and enter the number of intending immigrants, indicated in Part 5. The filer should inform if they have appealed to the services of an interpreter when filling in the form, and enter their contact details. The filer should confirm the provided information by their printed name, signature, and date.
  7. If during the process of completing this form the filers appealed to the services of an interpreter, this interpreter should provide their full name, mailing address, phone number, and email in Part 7.
  8. If there is any individual who has provided support in filling out the form, their full name, mailing address, and contact details must be entered in Part 8. The preparer must indicate if they are an attorney or accredited representative and sign this section. If the interpreter and the preparer are the same person, this individual must fill in Part 7 and Part 8.
  9. Part 9 contains extra space for any additional information.
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USCIS
Contract Between Sponsor and Household Member
Form I-864A
Department of Homeland Security
OMB No. 1615-0075
U.S. Citizenship and Immigration Services
Expires 10/31/2021
For Government Use Only
This Form I-864A relates to a household member who:
IS the intending
IS NOT the
Reviewed By:
immigrant
intending
Location:
Date (mm/dd/yyyy):
immigrant
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
To be completed by an
Form G-28 or
(if applicable)
USCIS Online Account Number (if any)
attorney or accredited
G-28I is attached.
representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You (the Household
Physical Address
Member)
4.a.
Street Number
and Name
Full Name
4.b.
Apt.
Ste.
Flr.
1.a. Family Name
(Last Name)
4.c. City or Town
1.b. Given Name
(First Name)
4.d. State
4.e. ZIP Code
1.c. Middle Name
4.f.
Province
Mailing Address
(USPS ZIP Code Lookup)
4.g. Postal Code
2.a. In Care Of Name
4.h.
Country
2.b.
Street Number
and Name
Other Information
2.c.
Apt.
Ste.
Flr.
5.
Date of Birth (mm/dd/yyyy)
2.d. City or Town
Place of Birth
2.e. State
2.f.
ZIP Code
6.a.
City or Town
2.g.
Province
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
7.
U.S. Social Security Number (if any)
address?
Yes
No
If you answered "No" to Item Number 3., provide your
8.
USCIS Online Account Number (if any)
physical address.
Form I-864A 10/15/19
Page 1 of 8
USCIS
Contract Between Sponsor and Household Member
Form I-864A
Department of Homeland Security
OMB No. 1615-0075
U.S. Citizenship and Immigration Services
Expires 10/31/2021
For Government Use Only
This Form I-864A relates to a household member who:
IS the intending
IS NOT the
Reviewed By:
immigrant
intending
Location:
Date (mm/dd/yyyy):
immigrant
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
To be completed by an
Form G-28 or
(if applicable)
USCIS Online Account Number (if any)
attorney or accredited
G-28I is attached.
representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You (the Household
Physical Address
Member)
4.a.
Street Number
and Name
Full Name
4.b.
Apt.
Ste.
Flr.
1.a. Family Name
(Last Name)
4.c. City or Town
1.b. Given Name
(First Name)
4.d. State
4.e. ZIP Code
1.c. Middle Name
4.f.
Province
Mailing Address
(USPS ZIP Code Lookup)
4.g. Postal Code
2.a. In Care Of Name
4.h.
Country
2.b.
Street Number
and Name
Other Information
2.c.
Apt.
Ste.
Flr.
5.
Date of Birth (mm/dd/yyyy)
2.d. City or Town
Place of Birth
2.e. State
2.f.
ZIP Code
6.a.
City or Town
2.g.
Province
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
7.
U.S. Social Security Number (if any)
address?
Yes
No
If you answered "No" to Item Number 3., provide your
8.
USCIS Online Account Number (if any)
physical address.
Form I-864A 10/15/19
Page 1 of 8
NOTE: You MUST attach a photocopy or transcript of
Part 2. Your (the Household Member's)
your Federal income tax return for only the most recent
Relationship to the Sponsor
tax year.
Select Item Number 1.a., 1.b., or 1.c.
(Optional) I have attached photocopies or transcripts
1.b.
of my Federal income tax returns for my second and
1.a.
I am the intending immigrant and also the sponsor's
third most recent tax years.
spouse.
1.b.
I am the intending immigrant and also a member of
My total income (adjusted gross income on IRS Form 1040EZ)
the sponsor's household.
as reported on my Federal income tax returns for the most
recent three years was:
1.c.
I am not the intending immigrant. I am the sponsor's
household member. I am related to the sponsor as
Tax Year
Total Income
his/her:
2.a.
Most Recent
$
Spouse
2.b. 2nd Most Recent
$
Son or Daughter (at least 18 years of age)
2.c.
3rd Most Recent
$
Parent
My assets (complete only if necessary).
Brother or Sister
3.a.
Enter the balance of all cash, savings, and checking
accounts.
Other Dependent (Specify)
$
3.b.
Enter the net cash value of real-estate holdings. (Net
value means assessed value minus mortgage debt.)
Part 3. Your (the Household Member's)
$
Employment and Income
3.c.
Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item Numbers 3.a.
I am currently:
or 3.b.
$
1.
Employed as a/an
3.d.
Add together Item Numbers 3.a., 3.b., and 3.c. and enter
the number here.
$
2.
Name of Employer Number 1
Part 5. Sponsor's Promise, Statement, Contact
3.
Name of Employer Number 2 (if applicable)
Information, Declaration, Certification, and
Signature
4.
Self employed as a/an
NOTE: Read the Penalties section of the Form I-864A
Instructions before completing this part.
5.
Retired from (Company Name)
I, THE SPONSOR,
,
(Print Name)
Since (mm/dd/yyyy)
in consideration of the household member's promise to support
6.
Unemployed since (mm/dd/yyyy)
the following intending immigrants and to be jointly and
severally liable for any obligations I incur under the affidavit of
7.
My current individual annual income is:
support, promise to complete and file an affidavit of support on
$
behalf of the following named intending immigrants.
Part 4. Your (the Household Member's) Federal
(Indicate Number)
Income Tax Information and Assets
Have you filed a Federal income tax return for each of the
1.a.
three most recent tax years?
Yes
No
Form I-864A 10/15/19
Page 2 of 8
13.
Alien Registration Number (A-Number, if any)
Part 5. Sponsor's Promise, Statement, Contact
A-
Information, Declaration, Certification, and
Signature (continued)
14.
U.S. Social Security Number (if any)
Intending Immigrant Number 1
Name
15.
USCIS Online Account Number (if any)
1.a. Family Name
(Last Name)
1.b. Given Name
Intending Immigrant Number 4
(First Name)
Name
1.c. Middle Name
16.a. Family Name
(Last Name)
2.
Date of Birth (mm/dd/yyyy)
16.b. Given Name
(First Name)
3.
Alien Registration Number (A-Number, if any)
A-
16.c. Middle Name
4.
U.S. Social Security Number (if any)
17.
Date of Birth (mm/dd/yyyy)
18.
Alien Registration Number (A-Number, if any)
5.
USCIS Online Account Number (if any)
A-
19.
U.S. Social Security Number (if any)
Intending Immigrant Number 2
Name
20.
USCIS Online Account Number (if any)
6.a. Family Name
(Last Name)
6.b. Given Name
Intending Immigrant Number 5
(First Name)
Name
6.c. Middle Name
21.a. Family Name
(Last Name)
7.
Date of Birth (mm/dd/yyyy)
21.b. Given Name
(First Name)
8.
Alien Registration Number (A-Number, if any)
A-
21.c. Middle Name
9.
U.S. Social Security Number (if any)
22.
Date of Birth (mm/dd/yyyy)
23.
Alien Registration Number (A-Number, if any)
10.
USCIS Online Account Number (if any)
A-
24.
U.S. Social Security Number (if any)
Intending Immigrant Number 3
Name
25.
USCIS Online Account Number (if any)
11.a. Family Name
(Last Name)
11.b. Given Name
Sponsor's Statement
(First Name)
11.c. Middle Name
NOTE: Select the box for either Item Number 26.a. or 26.b.
If applicable, select the box for Item Number 27.
12.
Date of Birth (mm/dd/yyyy)
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.
Form I-864A 10/15/19
Page 3 of 8
Part 5. Sponsor's Promise, Statement, Contact
Part 6. Your (the Household Member's) Promise,
Information, Declaration, Certification, and
Statement, Contact Information, Declaration,
Signature (continued)
Certification, and Signature
26.b.
The interpreter named in Part 7. read to me every
NOTE: Read the Penalties section of the Form I-864A
question and instruction on this contract and my
Instructions before completing this part.
answer to every question in
I, THE HOUSEHOLD MEMBER,
,
a language in which I am fluent, and I understood
,
everything.
(Print Name)
At my request, the preparer named in Part 8.,
in consideration of the sponsor's promise to complete and file an
27.
affidavit of support on behalf of the above named intending
,
immigrants.
prepared this contract for me based only upon
information I provided or authorized.
(Print number of intending immigrants noted in Part 5.
Sponsor's Contact Information
Sponsor's Promise, Statement, Contact Information,
Declaration, Certification and Signature.)
Sponsor's Daytime Telephone Number
28.
A.
Promise to provide any and all financial support
necessary to assist the sponsor in maintaining the
Sponsor's Mobile Telephone Number (if any)
29.
sponsored immigrants at or above the minimum
income provided for in the Immigration and
Naturalization Act (INA) section 213A(a)(1)(A)
30.
Sponsor's Email Address (if any)
(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
Sponsor's Declaration and Certification
of any and all obligations owed by the sponsor
Copies of any documents I have submitted are exact
under the affidavit of support to the sponsored
photocopies of unaltered, original documents, and I understand
immigrants, to any agency of the Federal
that U.S. Citizenship and Immigration Services (USCIS) or the
Government, to any agency of a state or local
U.S. Department of State (DOS) may require that I submit
government, or to any other private entity that
original documents to USCIS or DOS at a later date.
provides means-tested public benefits;
Furthermore, I authorize the release of any information from
C.
Certify under penalty under the laws of the United
any and all of my records that USCIS or DOS may need to
States that the Federal income tax returns submitted
determine my eligibility for the immigration benefit that I seek.
in support of the contract are true copies or
I furthermore authorize release of information contained in this
unaltered tax transcripts filed with the Internal
contract, in supporting documents, and in my USCIS or DOS
Revenue Service;
records, to other entities and persons where necessary for the
D.
Consideration where the household member is also
administration and enforcement of U.S. immigration law.
the sponsored immigrant: I understand that if I am
I certify, under penalty of perjury, that all of the information in
the sponsored immigrant and a member of the sponsor's
my contract and any document submitted with it were provided
household that this promise relates only to my promise
or authorized by me, that I reviewed and understand all of the
to be jointly and severally liable for any obligation
information contained in, and submitted with, my contract and
owed by the sponsor under the affidavit of support to
that all of this information is complete, true, and correct.
any of my dependents, to any agency of the Federal
Government, to any agency of a state or local
Sponsor's Signature
government, or to any other private entity that provides
means-tested public benefits and to provide any and all
31.a.
Sponsor's Signature
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)
31.b.
Date of Signature
(mm/dd/yyyy)
(1)(A) (not less than 125 percent of the Federal Poverty
Guideline) during the period which the affidavit of
NOTE TO ALL SPONSORS: If you do not completely fill
support is enforceable.
out this contract or fail to submit required documents listed in
the Instructions, USCIS may deny your contract.
Form I-864A 10/15/19
Page 4 of 8
Part 6. Your (the Household Member's) Promise,
Your (the Household Member's) Declaration and
Statement, Contact Information, Declaration,
Certification
Certification, and Signature (continued)
Copies of any documents I have submitted are exact
E.
I understand that, if I am related to the sponsored
photocopies of unaltered, original documents, and I understand
immigrant or the sponsor by marriage, the
that USCIS or DOS may require that I submit original
termination of the marriage (by divorce, dissolution,
documents to USCIS or DOS at a later date. Furthermore, I
annulment, or other legal process) will not relieve
authorize the release of any information from any and all of my
me of my obligations under this Form I-864A.
records that USCIS or DOS may need to determine my
F.
I authorize the Social Security Administration to
eligibility for the immigration benefit that I seek.
release information about me in its records to the
I furthermore authorize release of information contained in this
Department of State and U.S. Citizenship and
contract, in supporting documents, and in my USCIS or DOS
Immigration Services (USCIS).
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
Your (the Household Member's) Statement
I certify, under penalty of perjury, that all of the information in
NOTE: Select the box for either Item Number 1.a. or 1.b.
my contract and any document submitted with it were provided
If applicable, select the box for Item Number 2.
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my contract and
1.a.
I can read and understand English, and I have read
that all of this information is complete, true, and correct.
and understand every question and instruction on this
contract and my answer to every question.
Your (the Household Member's) Signature
1.b.
The interpreter named in Part 7. read to me every
question and instruction on this contract and my
6.a. Your (the Household Member's) Printed Name
answer to every question in
,
6.b.
Your (the Household Member's) Signature
a language in which I am fluent, and I understood
everything.
At my request, the preparer named in Part 8.,
2.
6.c.
Date of Signature
(mm/dd/yyyy)
,
NOTE TO ALL HOUSEHOLD MEMBERS: If you do not
prepared this contract for me based only upon
completely fill out this contract or fail to submit required
information I provided or authorized.
documents listed in the Instructions, USCIS may deny your
contract.
Your (the Household Member's) Contact
Information
Part 7. Interpreter's Contact Information,
Your (the Household Member's) Daytime Telephone
3.
Certification, and Signature
Number
Provide the following information about the interpreter.
Your (the Household Member's) Mobile Telephone
4.
Interpreter's Full Name
Number (if any)
1.a.
Interpreter's Family Name (Last Name)
5.
Your (the Household Member's) Email Address (if any)
1.b.
Interpreter's Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
Form I-864A 10/15/19
Page 5 of 8
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