Form I-864 - Affidavit Of Support Under Section 213a Of The Act Page 12
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16Part 1. Information on Sponsor's Household Member or Sponsored Immigrant/Household Member
Last Name
First Name
Middle Name
Date of Birth (Month,Day, Year) Social Security Number (Mandatory for
A-Number (If any)
non-citizens; voluntary for U.S. citizens)
Address (Street Number and Name)
Apt Number
City
State/Province
ZIP/Postal Code
Telephone Number
Relationship to Sponsor:
Length of residence with sponsor
I am:
(
)
The sponsor's household member.
(Complete Part 3.)
months)
years,
The sponsored immigrant/household member.
(Complete Part
Part 2. Sponsor's Promise
,
I, THE SPONSOR,
in consideration of the household member's promise to support the
(Print name of sponsor)
sponsored 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
sponsored immigrant(s):
(Indicate number)
Name of Sponsored Immigrant
Date of Birth
Social Security Number
A-Number
(If any)
(If any)
(First, Middle, Last)
(Month, Day, Year)
Part 3. Household Member's Promise
I, THE HOUSEHOLD
, in consideration of the sponsor's
(Print name of household member)
promise to complete and file the affidavit of support on behalf of the sponsored immigrant(s):
1) Promise to provide any and all financial support necessary to assist the sponsor in maintaining the sponsored immigrant(s)
at or above the minimum income provided for in section 213A(a)(1)(A) of the Act (not less than 125 percent of the
Federal Poverty Guidelines) during the period in which the affidavit of support is enforceable;
2) 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 immigrant(s), to any agency of the Federal Government, to any agency of a state or local
government, or to any private entity;
3)
Agree to submit to the personal jurisdiction of any court of the United States or of any state, territory, or possession of the
United States if the court has subject matter jurisdiction of a civil lawsuit to enforce this contract or the affidavit of
support; and
4)
Certify under penalty of perjury under the laws of the United States that all the information provided on this form is true
and correct to the best of my knowledge and belief and that the income tax returns I submitted in support of the sponsor
affidavit are true copies of the returns filed with the Internal Revenue Service.
Form I-864A (11/05/01)Y Page 2
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