Form I-864a - Contract Between Sponsor And Household Member
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8USCIS
Contract Between Sponsor and Household Member
Form I-864A
Department of Homeland Security
OMB No. 1615-0075
U.S. Citizenship and Immigration Services
Expires 07/31/2017
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
►
START HERE - Type or print in black ink.
Physical Address
Part 1. Information About You (the Household
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
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 ELIS Account Number (if any)
physical address.
►
Form I-864A 07/02/15 N
Page 1 of 8
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