Form I-134 11/30/16 N Page 5 of 8
Part 4. Sponsor's Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-134
Instructions before completing this part.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
I can read and understand English, and I have read and
understand every question and instruction on this
affidavit and my answer to every question.
The interpreter named in Part 5. read to me every
question and instruction on this affidavit and my
answer to every question in
a language in which I am fluent and I understood
At my request, the preparer named in Part 6.,2.
Sponsor's Email Address (if any)
Sponsor's Mobile Telephone Number (if any)4.
Sponsor's Daytime Telephone Number3.
Sponsor's Contact Information
prepared this affidavit for me based only upon
information I provided or authorized.
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS or
the Department of State may require that I submit original
documents to USCIS or the Department of State at a later date.
Furthermore, I authorize the release of any information from any
of my records that USCIS or the Department of State may need
to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this
affidavit, in supporting documents, and in my USCIS or the
Department of State records to other entities and persons where
necessary for the administration and enforcement of U.S.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my affidavit, I understand all of the
information contained in, and submitted with, my affidavit, and
that all of this information is complete, true, and correct.
That this affidavit is made by me to assure the U.S. Government
that the person named in Part 2. will not become a public
charge in the United States.
That I am willing and able to receive, maintain, and support the
person named in Part 2. I am ready and willing to deposit a
bond, if necessary, to guarantee that such persons will not
become a public charge during his or her stay in the United
States, or to guarantee that the above named persons will
maintain his or her nonimmigrant status, if admitted
temporarily, and will depart prior to the expiration of his or her
authorized stay in the United States.
That I understand that Form I-134 is an "undertaking" under
section 213 of the Immigration and Nationality Act, and I may
be sued if the persons named in Part 2. become a public charge
after admission to the United States.
That I understand that if the person named in Part 2. does apply
for Food Stamps, Supplemental Security Income, or Temporary
Assistance for Needy Families, my own income and assets may
be considered in deciding the person's application. How long
my income and assets may be attributed to the persons named in
Part 2. is determined under the statutes and rules governing
each specific program.
That I understand that Form I-134 may be made available to any
Federal, State, or local agency that may receive an application
from the persons named in Part 2. for Food Stamps,
Supplemental Security Income, or Temporary Assistance to
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the
information in my affidavit;
2) I understood all of the information contained in, and
submitted with, my affidavit; and
3) All of this information was complete, true, and correct at
the time of filing.
6.b. Date of Signature (mm/dd/yyyy)
I acknowledge that I have read the section entitled Sponsor and
Beneficiary Liability in the Instructions for this affidavit, and am
aware of my responsibilities as a sponsor under the Social
Security Act, as amended, and the Food Stamp Act, as amended.