Form I-864 - Affidavit Of Support Under Section 213a Of The Act Page 13
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16Part 4. Sponsored Immigrant/Household Member's Promise
I, THE SPONSORED IMMIGRANT/HOUSEHOLD
(Print name o f sponsored immigrant)
in consideration of the sponsor's promise to complete and file the affidavit of support on behalf of the sponsored immigrant(s)
accompanying me:
1) Promise to provide any and all financial support necessary to assist the sponsor in maintaining any sponsored
immigrant(s) immigrating with me 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;
2)
Agree to be jointly and severally liable for payment of any and all obligations owed by the sponsor under the affidavit of
support to any sponsored immigrant(s) immigrating with me, to any agency of the Federal Government, to any agency of
a state or local government, or to any private entity;
3)
Agree to submit to the personal jurisdiction of any court of the United States or of any state, territory, or possession of
the United States if the court has subject matter jurisdiction of a civil lawsuit to enforce this contract or the affidavit of
support; and
4)
Certify under penalty of perjury under the laws of the United States that all the information provided on this form is tru
and correct to the best of my knowledge and belief and that the income tax returns I submitted in support of the
sponsor's affidavit of support are true copies of the returns filed with the Internal Revenue Service.
Part 5. Sponsor's Signature
Date:
Sponsor's Signature
,
day of
Subscribed and sworn to (or affirmed) before me this
(Month)
(Year)
.
.
at
My commission expires on
Signature of Notary Public or Officer Administering Oath
Title
Part 6. Household Member's or Sponsored Immigrant/Household Member's Signature
Date:
Household Member's or Sponsored Immigrant/Household Member's Signature
,
day of
Subscribed and sworn to (or affirmed) before me this
(Month)
(Year)
.
.
at
My commission expires on
Signature of Notary Public or Officer Administering Oath
Title
Form I-864A (11/05/01)Y Page 3
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