Form I-134 02/19/14 Y Page 1
OMB No. 1615-0014; Expires 02/29/2016
(Answer all items. Type or print in black ink.)
1. I was born on
(City)
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:
a. If a U.S.citizen through naturalization, give Certificate of Naturalization number
c. If U.S. citizenship was derived by some other method, attach a statement of explanation.
d. If a Lawful Permanent Resident of the United States, give A-Number
2. I am years of age and have resided in the United States since
3. This affidavit is executed on behalf of the following person:
Gender Age
(Middle Name)
Citizen of (Country) Relationship to SponsorMarital Status
Presently resides at (Street Number and Name) (Country)(City) (State)
Name of spouse and children accompanying or following to join person:
Child Gender Age
Child Gender Age
Child Gender Age
Spouse Age
Child
Child Gender Age
4. This affidavit is made by me for the purpose of assuring the U.S. Government that the person(s) named in item (3) will not become a public
charge in the United States.
in
certify under penalty of perjury under U.S. law, that:
Gender
Gender
Age
(Date [mm/dd/yyyy]) (Country)
b. If a U.S. citizen through parent(s) or marriage, give Certificate of Citizenship number
Name (Family Name)
(First Name)
, residing at
I,
(Street Number and Name)(Name)
(Zip Code if in U.S.)
(Country)
(State)
(City)
Form I-134, Affidavit of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services
e. If a lawfully admitted nonimmigrant, give Form I-94, Arrival-Departure Record, number
5. I am willing and able to receive, maintain, and support the person(s) named in item 3. I am ready and willing to deposit a bond, if necessary, to
guarantee that such person(s) will not become a public charge during his or her stay in the United States, or to guarantee that the above named
person(s) 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.
6. I understand that:
a. Form I-134 is an “undertaking” under section 213 of the Immigration and Nationality Act, and I may be sued if the person(s) named in item 3
becomes a public charge after admission to the United States;
b. Form I-134 may be made available to any Federal, State, or local agency that may receive an application from the person(s) named in item 3
for Food Stamps, Supplemental Security Income, or Temporary Assistance to Needy Families; and
c. If the person(s) named in item 3 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
person(s) named in item 3 is determined under the statutes and rules governing each specific program.
(Date [mm/dd/yyyy])
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(State)
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,
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