Form I-864a (Rev. 10/08/10) - Contract Between Sponsor And Household Member Template

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OMB No. 1615-0075; Expires 10/31/2011
I-864A, Contract Between
Department of Homeland Security
Sponsor and Household Member
U.S. Citizenship and Immigration Services
For Government
Part 1. Information on the Household Member. (You.)
Use Only
1. Name
Last Name
This I-864A relates to
a household member
First Name
Middle Name
who:
2. Mailing Address
Street Number and Name (include apartment number)
is the intending
immigrant.
State or Province
City
is not the intending
Country
Zip/Postal Code
immigrant.
Street Number and Name (include apartment number)
3. Place of Residence
(if different from
mailing address)
City
State or Province
Reviewer
Country
Zip/Postal Code
Location
4. Telephone Number
(Include area code or country and city codes)
Date (mm/dd/yyyy)
(mm/dd/yyyy)
5. Date of Birth
6. Place of Birth
City
State/Province
Country
7. U.S. Social Security
Number (if any)
8.
Relationship to Sponsor (Check either a, b or c.)
a.
I am the intending immigrant and also the sponsor's spouse.
I am the intending immigrant and also a member of the sponsor's household.
b.
c.
I am not the intending immigrant. I am the sponsor's household member. I am
related to the sponsor as his/her.
Spouse
Son or daughter (at least 18 years old)
Parent
Brother or sister
Other dependent (specify)
Form I-864A (Rev. 10/08/10)Y

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