Instructions For Form I-864a - Contract Between Sponsor And Household Member (Page 3 of 9) in pdf

3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been

married and the question asks “Provide the name of your current spouse”), type or print “N/A,” unless otherwise

directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many

children do you have” or “How many times have you departed the United States”), type or print “None,” unless

otherwise directed.

Specific Instructions

This contract is divided into nine parts. The sponsor completes Part 5. Sponsor’s Promise, Statement, Contact

Information, Certification, and Signature of this contract and the household member completes Parts 1., 2., 3., 4., and

6. The information below provides detailed information to help you complete this contract.

Part 1. Information About You (the Household Member)

Item Numbers l.a. - l.c. Full Name. Provide your full name.

Item Numbers 2.a. - 3. Mailing Address. Provide the address where you receive mail.

Item Numbers 4.a. - 4.h. Physical Address. If you reside in a location different than where you receive mail, provide

the address in the space provided.

Item Number 5. Date of Birth. Provide your date of birth in the mm/dd/yyyy format.

Item Number 6.a. - 6.c. Place of Birth. Provide the city or town, state or province, and country where you were born.

Item Number 7. U.S. Social Security Number (if any). Provide your U.S. Social Security Number if you have one.

Item Number 8. USCIS ELIS Account Number (if any). If you have previously filed an application, petition, or

request using the USCIS Electronic Immigration System (USCIS ELIS), provide the USCIS ELIS Account Number you

were issued by the system. The USCIS ELIS Account Number is not the same as an A-Number. If you were issued a

USCIS ELIS Account Number, enter it in the space provided.

Part 2. Your (the Household Member’s) Relationship to the Sponsor

Item Numbers 1.a. - 1.c. Select the item which best reflects your relationship to the sponsor.

If you select Item Number 1.a. (married to the sponsor), you do not have to reside with the sponsor, but you must provide

proof that your income will continue from the same source after immigration.

If you select Item Number 1.b. (not married to the sponsor), you must provide proof that you currently have the same

principal residence as the sponsor and that your income will continue from the same source after immigration.

If you are the household member completing this contract, but are not the intending immigrant, select Item Number 1.c.,

and select the box below that describes your relationship to the sponsor. If you select “Other dependent,” you must be

listed as a dependent on the sponsor’s most recent Federal income tax return. You do not have to provide proof that you

have the same principal residence as the sponsor. If you select any other relative except for spouse, you must provide

proof of the relationship and that you have the same principal residence as the sponsor.

Part 3. Your (the Household Member’s) Employment and Income

Item Number 1.a. - 1.d. Your (the Household Member’s) Employment.

Select all boxes that apply to you. A sponsor may not rely on a household member’s income from illegal activities, such

as proceeds from illegal gambling or drug sales, to meet the income requirements, even if the household member paid

taxes on that income.

Item Number 2. Current Individual Annual Income. Enter your current individual earned or retirement annual income

that you are using to meet the requirements of this contract and indicate the total on this line.

Form I-864A Instructions 07/02/15 N

Page 3 of 9

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