3 4 5 9  Lawrenceville - Suwanee  Rd., Suite A,  Suwanee ,  Georgia

Tel: (770) 271-5244 ● Toll Free:  (888) 768-7252 ● Fax: (770) 271-5604 ● Cornel@PotraLawFirm.com ● www.potralawfirm.com

Attorneys;  Cornel Potra – Admitted: Georgia & Washington  ●  Kristina F Potra – Admitted: Georgia

This questionnaire is for the exclusive use of Potra Law Firm.  Please answer all the questions.  Do not leave any questions unanswered.  If you do not have an answer to a question, please insert “N/A”.  It is your responsibility to provide true and accurate information, as well as the evidentiary documents requested.

This Document Is For The Attorney’s Office Use Only

 

  

 

QUESTIONNAIRE I-864A

AFFIDAVIT OF SUPPORT – INFO AND DOCUMENTS NEEDED FROM THE CO-SPONSOR

 

 

Personal Information

 

1. Full Name

a. Family name

 b. First name

c. Middle name

 
 

2. Mailing address

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

 

   e. Country

   f. Telephone

 

 

3. Place of residence (if different than the mailing address):

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

 

   e. Country

   f. Telephone

 

 

 

4. Date of Birth month/day/year

5. Place of birth City/State/Country

6. Social Security Number

 

 

7. Please indicate your relationship with the sponsor by selecting one of the following:

 
 
 

 
       I am related to the sponsor as his/her
      Other relative
 
 

8. Please select one of the following, and give details:

     Name of employer          
company's name
month/day/year  
 
9. Your current individual income
10. Did you file federal taxes for the last three fiscal years?
 

11. Indicate the individual annual income for the last three fiscal years:

 

Tax year

Total Income
a.

b.

c.

 

 

Please indicate:

12. The balance of all cash,  savings and checking accounts

   

13. The net cash value of real-estate holdings (net means assessed value minus mortgage debt)

  

14. Indicate the net cash value of all stocks, bonds, certificates of deposit,

      and any other assets not included above
 
   

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

Documents necessary to file I-864 A to the U.S. Department of Homeland Security:

 

  
* Your federal tax income returns for the last three fiscal years
 
 
*

Letter from current employer (must be on company letterhead) attesting to:

a. Your Name;

b. Position (occupation);

c. Rate of Pay;

d. Date of employment. 

The letter should contain the company's header and signature of the legal representative.

If you are self-employed, please write a personal letter and mention the nature of your business, the date when you started and the income.

Please don't forget to sign it.

 

  
 
 
 
 
 
 
 
 
*

A copy of the Citizenship Certificate, Passport, or Birth Certificate, or, if you are not a U.S. citizen, a copy of your Green Card.

  
 
 
 
     

NOTE: THIS DOCUMENT IS THE PRODUCT OF POTRA LAW FIRM. THE USE OF THIS QUESTIONNAIRE BY OTHER INDIVIDUALS OR LAW FIRMS IN ASSISTING OTHERS WITH THE COMPLETION OF DOCUMENTS, OR FOR ANY OTHER PURPOSES, IS STRICTLY PROHIBITED.   POTRA LAW FIRM MAINTAINS ITS COPYRIGHTS OVER THE TRANSLATION OF THIS DOCUMENT.  PERMISSION TO USE THIS DOCUMENT MAY BE OBTAINED ONLY FROM POTRA LAW FIRM.  COPYRIGHT © January 17, 2007.