Form I-864a - Contract Between Sponsor And Household Member - U.s. Citizenship And Immigration Services Page 3

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9.
U.S. Social Security Number (if any)
Part 5. Sponsor's Promise, Statement, Contact
►
Information, Certification, and Signature
10.
USCIS ELIS Account Number (if any)
NOTE: Read the information on penalties in the Penalties
►
section of the Form I-864A Instructions before completing this
part.
Intending Immigrant Number 3:
I, THE SPONSOR,
Name
11.a. Family Name
,
(Last Name)
(Print Name)
11.b. Given Name
in consideration of the household member's promise to support
(First Name)
the following intending immigrant(s) and to be jointly and
11.c. Middle Name
severally liable for any obligations I incur under the affidavit of
support, promise to complete and file an affidavit of support on
12.
Date of Birth
(mm/dd/yyyy)
behalf of the following named intending immigrant(s).
13.
A-Number (if any)
►
A-
(Indicate Number)
14.
U.S. Social Security Number (if any)
Intending Immigrant Number 1:
►
Name
15.
USCIS ELIS Account Number (if any)
1.a. Family Name
►
(Last Name)
1.b. Given Name
Intending Immigrant Number 4:
(First Name)
Name
1.c. Middle Name
16.a. Family Name
2.
Date of Birth
(mm/dd/yyyy)
(Last Name)
16.b. Given Name
3.
A-Number (if any)
(First Name)
►
A-
16.c. Middle Name
4.
U.S. Social Security Number (if any)
17.
Date of Birth
(mm/dd/yyyy)
►
18.
A-Number (if any)
5.
USCIS ELIS Account Number (if any)
►
A-
►
19.
U.S. Social Security Number (if any)
Intending Immigrant Number 2:
►
Name
20.
USCIS ELIS Account Number (if any)
6.a. Family Name
►
(Last Name)
6.b. Given Name
Intending Immigrant Number 5:
(First Name)
Name
6.c. Middle Name
21.a. Family Name
7.
Date of Birth
(mm/dd/yyyy)
(Last Name)
21.b. Given Name
8.
A-Number (if any)
(First Name)
►
A-
21.c. Middle Name
Form I-864A 07/02/15 N
Page 3 of 8

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