Form I-134 11/30/16 N Page 1 of 8
Affidavit of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-134
OMB No. 1615-0014
Expires 11/30/2018
START HERE - Type or print in black ink.
Part 1. Information About You (the Sponsor)
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Your Full Name
Other Names Used
List all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Sponsor's Mailing Address
3.d.
3.e.
3.b.
3.c.
3.h.
3.i.
3.g.
City or Town
State 3.f. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Ste. Flr.
In Care Of Name
3.a.
4. Are your mailing address and physical address the same?
No
Yes
If you answered "No" to Item Number 4., provide your
physical address in Item Numbers 5.a. - 5.h.
Sponsor's Physical Address
5.b.
5.c.
5.a.
5.f.
5.g.
5.d.
5.h.
City or Town
State 5.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Ste. Flr.
Apt.
Other Information
6. Date of Birth (mm/dd/yyyy)
7.a. Town or City
of Birth
U.S. Social Security Number (if any)9.
USCIS Online Account Number (if any)10.
A-
Alien Registration Number (A-Number) (if any)8.
7.b. Country
of Birth
If you are not a U.S. citizen based on your birth in the United
States, or a non-citizen U.S. national based on your birth in
American Samoa (including Swains Island), answer the
following as appropriate:
Citizenship or Residency or Status
11.a.
I am a U.S. citizen through parent(s) or marriage.
My Certificate of Citizenship number is
11.b.
I am a U.S. citizen through naturalization. My
Certificate of Naturalization number is
Form I-134 11/30/16 N Page 2 of 8
Part 1. Information About You (the Sponsor)
(continued)
I derived my U.S. citizenship by another method.
(Provide an explain in Part 7. Additional
Information.)
11.c.
11.d.
I am a lawfully admitted nonimmigrant. My
Form I-94, Arrival-Departure Record Number is
11.e.
I am a lawful permanent resident of the
United States. My A-Number is
12.
Part 2. Information About the Beneficiary
I am
States since (Date) (mm/dd/yyyy)
years of age and have resided in the United
This affidavit is executed on behalf of the following person:
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. Date of Birth (mm/dd/yyyy)
Male Female3. Gender
A-
A-Number (if any)4.
5. Country of Citizenship or Nationality
8.c.
8.d.
8.a.
8.b.
8.g.
8.h.
8.f.
City or Town
State 8.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Ste. Flr.
Apt.
A-
Marital Status6.
Married
Legally Separated
Widowed
Single or Single, Never Married
Divorced
Other
Marriage Annulled
Relationship to Sponsor
7.
Beneficiary's Physical Address
Beneficiary's Spouse (accompanying or following
to join beneficiary)
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
10. Date of Birth (mm/dd/yyyy)
Gender14. FemaleMale
Male Female11. Gender
Beneficiary's Children
Child 1
12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)
12.c. Middle Name
13. Date of Birth (mm/dd/yyyy)
Child 2
15.a. Family Name
(Last Name)
15.b. Given Name
(First Name)
15.c. Middle Name
16. Date of Birth (mm/dd/yyyy)
Gender17. FemaleMale
If you need additional space to complete this section, use the
space provided in Part 7. Additional Information.
Form I-134 11/30/16 N Page 3 of 8
Part 3. Other Information About the Sponsor
Employment Information
1.b.
I am currently:
Employed as a/an1.a.
1.a.1.Name of Employer (if applicable)
Self employed as a/an
Current Employer Address (if employed)
2.c.
2.d.
2.a.
2.b.
2.g.
2.h.
2.f.
City or Town
State 2.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Ste. Flr.Apt.
Income and Asset Information
3. My annual income is $
(If self-employed, I have attached a copy of my last income tax
return or report of commercial rating concern which I certify to
be true and correct to the best of my knowledge and belief. See
Instructions for nature of evidence of net worth to be submitted.)
4.
$
5. Value of my other personal property
$
Balance of all my savings and checking accounts in
United States-based financial institutions
6. Market value of my stocks and bonds
$
I have listed my stocks and bonds in Part 7. Additional
Information (or attached a list of them), which I certify
to be
true and correct to the best of my knowledge and belief.
7.a. $
7.b. With a cash surrender value of
$
I have life insurance in the sum of
Real Estate Information
8.a. $
8.b. I have mortgages or other debts amounting to
$
I own real estate valued at
My real estate is located at:
9.c.
9.d.
9.a.
9.b.
City or Town
State 9.e. ZIP Code
Street Number
and Name
Ste. Flr.Apt.
Dependents' Information
The following persons are dependent upon me for support. If
you need extra space to complete this section, use the space
provided in Part 7. Additional Information.
10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)
10.c. Middle Name
11. Relationship to Me:
Date of Birth (mm/dd/yyyy)
13.
Wholly Dependent On Me For Support
Partially Dependent On Me For Support
12.
This person is:
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c. Middle Name
15. Relationship to Me:
16. Date of Birth (mm/dd/yyyy)
Form I-134 11/30/16 N Page 4 of 8
Part 3. Other Information About the Sponsor
(continued)
17.
Wholly Dependent On Me For Support
Partially Dependent On Me For Support
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name
This person is:
19.
Date of Birth (mm/dd/yyyy)
20.
Relationship to Me:
21.
Wholly Dependent On Me For Support
This person is:
Partially Dependent On Me For Support
I have previously submitted affidavit(s) of support for the
following person(s). (If none, write "None" in the space for
name below.)
22.a. Family Name
(Last Name)
22.b. Given Name
(First Name)
22.c.
Middle Name
Date Submitted (mm/dd/yyyy)23.
24.a. Family Name
(Last Name)
24.b. Given Name
(First Name)
24.c.
Middle Name
Date Submitted (mm/dd/yyyy)25.
33. Date of Filing (mm/dd/yyyy)
32.
Date of Birth (mm/dd/yyyy)
31. Relationship to Me:
Middle Name
30.c.
Given Name
(First Name)
30.b.
Family Name
(Last Name)
30.a.
Date of Birth (mm/dd/yyyy)28.
Date of Filing (mm/dd/yyyy)29.
I have submitted a visa petition(s) to U.S. Citizenship and
Immigration Services on behalf of the following persons. (If
none, write “None” in the space for name below.)
26.a. Family Name
(Last Name)
26.b. Given Name
(First Name)
26.c.
Middle Name
Relationship to Me:27.
37.
38. I intend
Date of Filing (mm/dd/yyyy)
36.
Date of Birth (mm/dd/yyyy)
35. Relationship to Me:
Middle Name
34.c.
Given Name
(First Name)
34.b.
Family Name
(Last Name)
34.a.
contributions to the support of the person(s) named in
Part 2.
(If you select "intend," indicate the exact nature and
duration of the contributions you intend to make in
Part 7. Additional Information. For example, if you
intend to furnish room and board, state for how long and,
if money, state the amount in U.S. dollars and whether it
is to be given in a lump sum, weekly or monthly, and for
how long.)
do not intend to make specific
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.
1.a.
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.
Sponsor's Statement
The interpreter named in Part 5. read to me every
question and instruction on this affidavit and my
answer to every question in
1.b.
a language in which I am fluent and I understood
everything.
,
At my request, the preparer named in Part 6.,2.
,
5.
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.
Sponsor's Certification
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.
immigration laws.
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
Needy Families.
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.
Sponsor's Signature6.a.
6.b. Date of Signature (mm/dd/yyyy)
Sponsor's Signature
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.
Form I-134 11/30/16 N Page 6 of 8
NOTE TO ALL SPONSORS: If you do not completely fill
out this affidavit or fail to submit required documents listed in
the Instructions, USCIS or the Department of State may deny
your affidavit.
Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
Interpreter's Business or Organization Name (if any)2.
Part 5. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h. Country
Street Number
and Name
3.a.
3.b.
Ste. Flr.Apt.
Interpreter's Daytime Telephone Number
5. Interpreter's Mobile Telephone Number (if any)
6.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language provided in Part 4., Item
Number 1.b., and I have read to this sponsor in the identified
language every question and instruction on this affidavit and his
or her answer to every question. The sponsor informed me that
he or she understands every instruction, question, and answer on
the affidavit, including the Sponsor's Certification, and has
verified the accuracy of every answer.
Interpreter's Signature
7.a.
7.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Part 6. Contact Information, Statement,
Declaration, and Signature of the Person
Preparing this Affidavit, if Other Than the
Sponsor
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h. Country
Street Number
and Name
3.a.
3.b.
Ste. Flr.Apt.
Form I-134 11/30/16 N Page 7 of 8
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Fax Number 5.
Preparer's Statement
I am an attorney or accredited representative and my
representation of the sponsor in this case
I am not an attorney or accredited representative but
have prepared this affidavit on behalf of the sponsor
and with the sponsor's consent.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this affidavit, you may be obliged to
submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this application.
7.a.
7.b.
extends
does not extend beyond the
preparation of this affidavit.
Part 6. Contact Information, Statement,
Declaration, and Signature of the Person
Preparing this Affidavit, if Other Than the
Sponsor (continued)
Preparer's Certification
Preparer's Signature
Preparer's Signature8.a.
8.b. Date of Signature (mm/dd/yyyy)
By my signature, I certify, under penalty of perjury, that I
prepared this affidavit at the request of the sponsor. The sponsor
then reviewed this completed affidavit and informed me that he
or she understands all of the information contained in, and
submitted with, his or her affidavit, including the Sponsor's
Certification, and that all of this information is complete, true,
and correct. I completed this affidavit based only on information
that the sponsor provided to me or authorized me to obtain or use.
Form I-134 11/30/16 N Page 8 of 8
Part 7. Additional Information
3.d.
If you need extra space to provide any additional information
within this affidavit, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this affidavit or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at
the top of each sheet; type or print the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
2. A-Number (if any)
3.a.
Page Number
3.b. Part Number 3.c. Item Number
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
4.d.
4.a.
Page Number 4.b. Part Number 4.c. Item Number
5.d.
5.a.
Page Number 5.b. Part Number 5.c. Item Number
A-
7.a.
Page Number
7.b. Part Number 7.c. Item Number
7.d.
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