Form I-864a - Contract Between Sponsor And Household Member Page 2
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8Part 2. Your (the Household Member's)
Part 4. Your (the Household Member's) Federal
Relationship to the Sponsor
Income Tax Information and Assets
I have filed a Federal income tax return for each of
Select Item Number 1.a., 1.b., or 1.c.
1.
the three most recent tax years. I have attached the
1.a.
I am the intending immigrant and also the sponsor's
required photocopy or transcript of my Federal
spouse.
income tax return for only the most recent tax year.
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
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
Brother or sister
third most recent tax years.
Other dependent (Specify)
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
3.b.
Enter the net cash value of real-estate holdings. (Net
value means assessed value minus mortgage debt.)
I am currently:
$
1.a.
Employed as a/an
3.c.
Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item Numbers 3.a.
1.a.1.
Name of Employer Number 1 (if applicable)
or 3.b.
$
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
(mm/dd/yyyy)
1.d.
Unemployed since
(mm/dd/yyyy)
2.
My current individual annual income is:
$
Form I-864A 07/02/15 N
Page 2 of 8
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