Contract Between Sponsor and Household Member

• Legal Form Number: I-864A
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

To be completed by an

attorney or accredited

representative (if any).

Contract Between Sponsor and Household Member

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-864A

OMB No. 1615-0075

Expires 12/31/2023

START HERE - Type or print in black ink.►

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

4.d. State 4.e. ZIP Code

Country4.h.

Other Information

4.g. Postal Code

USCIS Online Account Number (if any)

8.

►

Mailing Address

2.d. City or Town

2.e. State 2.f. ZIP Code

Country2.i.

2.h. Postal Code

Street Number

and Name

2.b.

2.c. Apt. Flr.Ste.

NoYes

Is your current mailing address the same as your physical

address?

3.

If you answered "No" to Item Number 3., provide your

physical address.

5. Date of Birth (mm/dd/yyyy)

City or Town6.a.

Country6.c.

7. U.S. Social Security Number (if any)

►

Province2.g.

Province4.f.

Place of Birth

State or Province6.b.

This Form I-864A relates to a household member who:

IS the intending

immigrant IS NOT the

intending

immigrant

For Government Use Only

Date (mm/dd/yyyy):

Reviewed By:

Location:

2.a. In Care Of Name

Physical Address

4.c. City or Town

Street Number

and Name

4.a.

4.b. Apt. Flr.Ste.

Attorney State Bar Number

(if applicable) Attorney or Accredited Representative

USCIS Online Account Number (if any)

Select this box if

Form G-28 or

G-28I is attached.

Full Name

Part 1. Information About You (the Household

Member)

Page 1 of 8Form I-864A 12/08/21

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