Form I-864a (Rev. 10/08/10) - Contract Between Sponsor And Household Member Template Page 3
Download a blank fillable Form I-864a (Rev. 10/08/10) - Contract Between Sponsor And Household Member Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form I-864a (Rev. 10/08/10) - Contract Between Sponsor And Household Member Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Part 2. Sponsor's Promise.
For Government
Use Only
13. I, THE SPONSOR,
(Print Name)
in consideration of the household member's promise to support the following intending immigrant(s)
and to be jointly and severally liable for any obligations I incur under the affidavit of support, promise
named intending
to complete and file an affidavit of support on behalf of the following
(Indicate Number)
immigrant(s) (see Step-by-Step instructions).
Date of Birth
U.S. Social Security
A-number
Name
(if any)
(mm/dd/yyyy)
Number
(if any)
a.
b.
c.
d.
e.
14.
(Sponsor's Signature)
(Date--mm/dd/yyyy)
Part 3. Household Member's Promise.
15.
I, THE HOUSEHOLD MEMBER,
(Print Name)
in consideration of the sponsor's promise to complete and file an affidavit of support on behalf of the
above
named intending immigrant(s):
(Number from line 13)
a.
Promise to provide any and all financial support necessary to assist the sponsor in maintaining the
sponsored immigrant(s) at or above the minimum income provided for in section 213A(a)(1)(A)
of the Act (not less than 125 percent of the Federal Poverty Guidelines) during the period in
which the affidavit of support is enforceable;
Agree to be jointly and severally liable for payment of any and all obligations owed by the
b.
sponsor under the affidavit of support to the sponsored immigrant(s), to any agency of the Federal
Government, to any agency of a State or local government, or to any other private entity that
provides means-tested public benefit;
c.
Certify under penalty under the laws of the United States that all the information provided on this
form is true and correct to the best of my knowledge and belief and that the Federal income tax
returns submitted in support of the contract are true copies or unaltered tax transcripts filed with
the Internal Revenue Service.
d. Consideration where the household member is also the sponsored immigrant: I understand
that if I am the sponsored immigrant and a member of the sponsor's household that this promise
relates only to my promise to be jointly and severally liable for any obligation owed by the
sponsor under the affidavit of support to any of my dependents, to any agency of the Federal
Government, to any agency of a State or local government, and to provide any and all financial
support necessary to assist the sponsor in maintaining any of my dependents at or above the
minimum income provided for in section 213A(s)(1)(A) of the Act (not less than 125 percent of
the Federal poverty line) during the period which the affidavit of support is enforceable.
e.
I authorize the Social Security Administration to release information about me in its records to the
Department of State and U.S. Citizenship and Immigration Services.
16.
(Household Member's Signature)
(Date--mm/dd/yyyy)
Form I-864A (Rev. 10/08/10)Y Page 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal