Académique Documents
Professionnel Documents
Culture Documents
Form I-864A
IS NOT the
intending
immigrant
Reviewed By:
Location:
Date (mm/dd/yyyy):
Physical Address
4.a. Street Number
and Name
4.b.
Apt.
Ste.
Flr.
Mailing Address
4.h. Country
Apt.
Other Information
Ste.
Flr.
5.
Province
Date of Birth
(mm/dd/yyyy)
Place of Birth
2.f.
ZIP Code
2.g. Province
6.b. State or Province
2.h. Postal Code
2.i.
Country
3.
6.c. Country
7.
8.
Page 1 of 8
1.
1.a.
1.b.
1.c.
Total Income
Spouse
Parent
Brother or sister
Other dependent (Specify)
1.a.1.
Employed as a/an
$
3.b. Enter the net cash value of real-estate holdings. (Net
value means assessed value minus mortgage debt.)
$
3.c. Enter the cash value of all stocks, bonds, certificates of
deposit, and other assets not listed on Item Numbers 3.a.
or 3.b.
$
1.a.2.
1.b.
1.c.
Since
1.d.
2.
3.d. Add together Item Numbers 3.a., 3.b., and 3.c. and enter
the number here.
$
(mm/dd/yyyy)
Unemployed since
(mm/dd/yyyy)
My current individual annual income is:
$
Page 2 of 8
9.
10.
I, THE SPONSOR,
Name
,
(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 to complete and file an affidavit of support on
behalf of the following named intending immigrant(s).
Date of Birth
13.
14.
(Indicate Number)
Intending Immigrant Number 1:
(mm/dd/yyyy)
Name
15.
Date of Birth
3.
4.
(mm/dd/yyyy)
5.
Date of Birth
18.
19.
Name
20.
(mm/dd/yyyy)
Date of Birth
(mm/dd/yyyy)
8.
Page 3 of 8
Sponsor's Certification
Date of Birth
23.
A-Number
(mm/dd/yyyy)
A-
24.
25.
Sponsor's Statement
NOTE: Select the box for either Item Number 26.a. or 26.b.
If applicable, select the box for Item Number 27.
26.a.
26.b.
is
,
a language in which I am fluent. I understand every
question and instruction on this contract as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
27.
Sponsor's Signature
(Print Name)
29.
30.
Page 4 of 8
C.
D.
E.
F.
1.b.
2.
is
4.
5.
Page 5 of 8
5.
Interpreter's Certification
I certify that:
Interpreter's Signature
Apt.
Flr.
Province
2.
3.h. Country
Page 6 of 8
Apt.
Ste.
Flr.
Province
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this contract on behalf of, at the request
of, and with the express consent of the household member and
sponsor. I completed this contract based only on responses the
household member and sponsor provided to me. After
completing the contract, I reviewed it and all of the household
member's and sponsor's responses with the household member
and sponsor, who agreed with every answer on the contract. If
the household member or sponsor supplied additional
information concerning a question on the contract, I recorded it
on the contract.
Preparer's Signature
8.a. Preparer's Signature
5.
6.
Preparer's Statement
7.a.
7.b.
Page 7 of 8
5.d.
6.d.
3.d.
4.d.
Page 8 of 8