Form I-864a (Rev. 10/08/10) - Contract Between Sponsor And Household Member Template Page 2
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39. I am currently:
For Government
Use Only
a.
Employed as a/an
.
Name of Employer # 1 (if applicable)
.
Name of Employer #2 (if applicable)
.
b.
Self-employed as a/an
.
c.
since
.
Retired from
(Company Name)
(mm/dd/yyyy)
d.
Unemployed since
(mm/dd/yyyy)
.
10
My current individual annual income is: $__________________________________________.
11. Federal income tax information.
I have filed a Federal tax return for each of the three most recent tax years. I have
attached the required photocopy or transcript of my Federal tax return for only the
most recent tax year.
My total income (adjusted gross income on IRS Form 1040EZ) as reported on my
Federal tax returns for the most recent three years was:
Tax Year
Total Income
$
(most recent)
(2nd most recent)
$
$
(3rd most recent)
(Optional) I have attached photocopies or transcripts of my Federal tax returns for my
second and third most recent tax years.
12. My assets (complete only if necessary).
a.
$___________________________.
Enter the balance of all cash, savings, and checking accounts.
b.
Enter the net cash value of real-estate holdings. (Net means
$___________________________.
assessed value minus mortgage debt.)
c.
Enter the cash value of all stocks, bonds, certificates of
$___________________________.
deposit, and other assets not listed on line a or b.
$___________________________.
d.
Add together Lines a, b, and c and enter the number here.
Form I-864A (Rev.10/08/10)Y Page 2
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