Form I-864a - Contract Between Sponsor And Household Member Page 6
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8Interpreter's Contact Information
Part 6. Your (the Household Member's) Promise,
Statement, Contact Information, Certification,
4.
Interpreter's Daytime Telephone Number
and Signature (continued)
I certify, under penalty of perjury, that the information in my
5.
Interpreter's Email Address (if any)
contract and any document submitted with my contract were
provided by me and are complete, true, and correct.
Your (the Household Member's) Signature
Interpreter's Certification
I certify that:
6.a. Your (the Household Member's) Printed Name
I am fluent in English and
,
which is the same language provided in Part 5., Item
6.b.
Your (the Household Member's) Signature
Number 26.b.;
I have read to this sponsor and household member every
question and instruction on this contract, as well as the answer
6.c.
Date of Signature
(mm/dd/yyyy)
to every question, in the language provided in Part 5., Item
Number 26.b.; and
Part 7. Interpreter's Contact Information,
The sponsor and household member have informed me that he
and/or she understands every instruction and question on the
Certification, and Signature
contract, as well as the answer to every question, and the
sponsor and household member verified the accuracy of every
Provide the following information about the interpreter.
answer.
Interpreter's Full Name
Interpreter's Signature
1.a.
Interpreter's Family Name (Last Name)
6.a.
Interpreter's Signature
1.b.
Interpreter's Given Name (First Name)
6.b.
Date of Signature
(mm/dd/yyyy)
2.
Interpreter's Business or Organization Name (if any)
Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Contract, If Other Than the
Interpreter's Mailing Address
Household Member
3.a.
Street Number
and Name
Provide the following information about the preparer.
3.b.
Apt.
Ste.
Flr.
Preparer's Full Name
3.c. City or Town
1.a. Preparer's Family Name (Last Name)
3.d. State
3.e. ZIP Code
1.b.
Preparer's Given Name (First Name)
3.f.
Province
3.g.
Postal Code
2.
Preparer's Business or Organization Name (if any)
3.h.
Country
Form I-864A 07/02/15 N
Page 6 of 8
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