Form I-864a - Contract Between Sponsor And Household Member Page 5
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8Your (the Household Member's) Statement
Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Certification,
NOTE: Select the box for either Item Number 1.a. or 1.b.
and Signature (continued)
If applicable, select the box for Item Number 2.
Agree to be jointly and severally liable for payment
1.a.
I can read and understand English, and have read and
B.
of any and all obligations owed by the sponsor
understand every question and instruction on this
under the affidavit of support to the sponsored
contract, as well as my answer to every question.
immigrants, to any agency of the Federal
1.b.
The interpreter named in Part 7. has also read to me
Government, to any agency of a state or local
every question and instruction on this contract, as
government, or to any other private entity that
well as my answer to every question, in
provides means-tested public benefits;
,
C.
Certify under penalty under the laws of the United
a language in which I am fluent. I understand every
States that the Federal income tax returns submitted
question and instruction on this contract as translated
in support of the contract are true copies or
to me by my interpreter, and have provided complete,
unaltered tax transcripts filed with the Internal
true, and correct responses in the language indicated
Revenue Service;
above.
D.
Consideration where the household member is
2.
I have requested the services of and consented to
also the sponsored immigrant: I understand that
if I am the sponsored immigrant and a member of
,
the sponsor's household that this promise relates
who
is
is not an attorney or accredited
only to my promise to be jointly and severally liable
representative, preparing this contract for me.
for any obligation owed by the sponsor under the
affidavit of support to any of my dependents, to any
Your (the Household Member's) Contact
agency of the Federal Government, to any agency
of a state or local government, and to provide any
Information
and all financial support necessary to assist the
Your (the Household Member's) Daytime Telephone
sponsor in maintaining any of my dependents at or
3.
Number
above the minimum income provided for in section
213A(a)(1)(A) of the INA (not less than 125 percent
of the Federal Poverty Guideline) during the period
Your (the Household Member's) Mobile Telephone
which the affidavit of support is enforceable.
4.
Number (if any)
E.
I understand that, if I am related to the sponsored
immigrant or the sponsor by marriage, the
termination of the marriage (by divorce, dissolution,
5.
Your (the Household Member's) Email Address (if any)
annulment, or other legal process) will not relieve
me of my obligations under this Form I-864A.
F.
I authorize the Social Security Administration to
Your (the Household Member's) Certification
release information about me in its records to the
Department of State and U.S. Citizenship and
Copies of any documents I have submitted are exact
Immigration Services (USCIS).
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 the
Department of State record to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws.
Form I-864A 07/02/15 N
Page 5 of 8
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