Form I-864a - Contract Between Sponsor And Household Member - U.s. Citizenship And Immigration Services Page 4
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8Sponsor's Certification
Part 5. Sponsor's Promise, Statement, Contact
Information, Certification, and Signature
Copies of any documents I have submitted are exact
(continued)
photocopies of unaltered, original documents, and I understand
that USCIS or the Department of State may require that I submit
22.
Date of Birth
(mm/dd/yyyy)
original documents to USCIS or the Department of State at a
later date. Furthermore, I authorize the release of any
23.
A-Number
information from any and all of my records that USCIS or the
►
A-
Department of State may need to determine my eligibility for
the immigration benefit that I seek.
24.
U.S. Social Security Number (if any)
I furthermore authorize release of information contained in this
►
contract, in supporting documents, and in my USCIS or
Department of State record to other entities and persons where
25.
USCIS ELIS Account Number (if any)
necessary for the administration and enforcement of U.S.
►
immigration laws.
I certify, under penalty of perjury, that the information in my
Sponsor's Statement
contract and any document submitted with my contract were
NOTE: Select the box for either Item Number 26.a. or 26.b.
provided by me and are complete, true, and correct.
If applicable, select the box for Item Number 27.
Sponsor's Signature
26.a.
I can read and understand English, and have read and
understand every question and instruction on this
31.a.
Sponsor's Signature
contract, as well as my answer to every question.
26.b.
The interpreter named in Part 7. has also read to me
every question and instruction on this contract, as
31.b.
Date of Signature
(mm/dd/yyyy)
well as my answer to every question, in
,
Part 6. Your (the Household Member's) Promise,
a language in which I am fluent. I understand every
Statement, Contact Information, Certification,
question and instruction on this contract as translated
to me by my interpreter, and have provided complete,
and Signature
true, and correct responses in the language indicated
NOTE: Read the information on penalties in the Penalties
above.
section of the Form I-864A Instructions before completing this
27.
I have requested the services of and consented to
part.
,
I, THE HOUSEHOLD MEMBER,
who
is
is not an attorney or accredited
representative, preparing this contract for me.
,
(Print Name)
Sponsor's Contact Information
in consideration of the sponsor's promise to complete and file an
affidavit of support on behalf of the above named intending
Sponsor's Daytime Telephone Number
28.
immigrants.
Sponsor's Mobile Telephone Number (if any)
29.
(Print number of intending immigrants noted in Part 5.
Sponsor's Promise, Statement, Contact Information,
Certification, and Signature.)
30.
Sponsor's Email Address (if any)
A.
Promise to provide any and all financial support
necessary to assist the sponsor in maintaining the
sponsored immigrants at or above the minimum
income provided for in section 213A(a)(1)(A) of the
Immigration and Naturalization Act (INA) (not less
than 125 percent of the Federal Poverty Guidelines)
during the period in which the affidavit of support is
enforceable;
Form I-864A 07/02/15 N
Page 4 of 8
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