Uscis I-864 Real Estate Consulting Agreement Page 6
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12Household Size
Poverty Guideline
Remarks
For
1
2
3
Year: 2 0
USCIS
4
5
6
Use
Poverty Line:
7
8
9
Only
$
Other
Part 6. Sponsor's Employment and Income
Part 7. Use of Assets to Supplement Income
(continued)
(Optional)
If your income, or the total income for you and your
17.
One or more of the people listed in Item Numbers
household, from Part 6., Item Numbers 19.a. - 19.c., exceeds
3., 6., 9., and 12. do not need to complete Form
the Federal Poverty Guidelines for your household size, YOU
I-864A because he or she is the intending immigrant
ARE NOT REQUIRED to complete this Part 7. Skip to
and has no accompanying dependents.
Part 8.
Name
Your Assets (Optional)
1.
Enter the balance of all savings and checking accounts.
Federal Income Tax Return Information
$
18.a.
Have you filed a Federal income tax return for each of the
2.
Enter the net cash value of real-estate holdings. (Net
three most recent tax years?
Yes
No
value means current assessed value minus mortgage debt.)
$
NOTE: You MUST attach a photocopy or transcript of
your Federal income tax return for only the most recent
3.
Enter the net cash value of all stocks, bonds, certificates
tax year.
of deposit, and any other assets not already included in
Item Number 1. or Item Number 2.
18.b.
(Optional) I have attached photocopies or transcripts
of my Federal income tax returns for my second and
$
third most recent tax years.
4.
Add together Item Numbers 1. - 3. and enter the
number here.
My total income (adjusted gross income on Internal Revenue
TOTAL:
$
Service (IRS) Form 1040EZ) as reported on my Federal income
tax returns for the most recent three years was:
Assets from Form I-864A, Part 4., Item Number 3.d., for:
Tax Year
Total Income
5.a.
Name of Relative
19.a.
Most Recent
$
19.b. 2nd Most Recent
$
5.b.
Your household member's assets from Form I-864A
19.c.
3rd Most Recent
$
(optional).
$
20.
I was not required to file a Federal income tax return
Assets of the principal sponsored immigrant (optional).
as my income was below the IRS required level and I
The principal sponsored immigrant is the person listed in
have attached evidence to support this.
Part 2., Item Numbers 1.a. - 1.c.
6.
Enter the balance of the sponsored immigrant's savings
and checking accounts.
$
Form I-864 07/02/15 N
Page 6 of 12
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