OMB No. 1615-0014; Exp. 04-30-07
I-134, Affidavit of Support
(Answer All Items: Type or Print in Black Ink.)
residing at
I,
(Street and Number)
(
Name
)
(Zip Code if in U.S.)
1. I was born on
(
Countr
y)
(City)
If you are not a native born United States citizen, answer the following as appropriate:
a. If a United States citizen through naturalization, give certificate of naturalization number
b. If a United States citizen through parent(s) or marriage, give citizenship certificate number
c. If United States citizenship was derived by some other method, attach a statement of explanation.
d. If a lawfully admitted permanent resident of the United States, give "A" number
2. That I am
years of age and have resided in the United States since (date)
3. That this affidavit is executed on behalf of the following person:
Gende
r
Age
N
ame (Family Name) (First Name) (Middle Name)
Citizen of
(
Countr
y)
Relationship to Sponsor
Marital Status
Presently resides at (Street and Number)
(Country)(City) (State)
N
ame of spouse and children accompanying or following to join person:
Child
Gender
Age
Child
Gender
Age
Child
Gender
Age
Spouse Age
Child
Child
Gende
r
Age
4.
5.
6.
with
7. That I am employed as or engaged in the business of
(Name of Concern)
(
T
yp
e of Business
)
at
(Zip Code)
(
State
)
(City)(Street and Number)
I derive an annual income of (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.)
I have on deposit in savings banks in the United States
I have other personal property, the reasonable value which is
$
U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Services
(Country)(State)
at
BEING DULY SWORN DEPOSE AND SAY:
That this affidavit is made by me for the purpose of assuring the United States Government that the person(s) named in
item 3 will not become a public charge in the United States.
That I am willing and able to receive, maintain and support the person(s) named in item 3. That 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.
That I understand this affidavit will be binding upon me for a period of three (3) years after entry of the person(s) named in
item 3 and that the information and documentation provided by me may be made available to the Secretary of Health and
Human Services and the Secretary of Agriculture, who may make it available to a public assistance agency.
$
$
Cit
Gende
r
Gende
r
Age
(Date-mm/dd/yyyy)
Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04)
I have stocks and bonds with the following market value, as indicated on the attached list,
which I certify to be true and correct to the best of my knowledge and belief.
With mortgage(s) or other encumbrance(s) thereon amounting to $
Which is located at
(Zip Code)
Cit
(
State
)
(
Street and Number
)
8.
N
ame of Perso
n
Wholly Dependent Partially Dependent Age Relationship to Me
9. That I have previously submitted affidavit(s) of support for the following person(s). If none, state "None.''
N
ame
10. That I have submitted visa petition(s) to the Bureau of Citizenship and Immigration Services (CIS) on behalf of the
following person(s). If none, state none.
Date submitte
d
Relationship
N
ame
11.
That I intend do not intend to make specific contributions to the support of the person(s) named in item 3.
(If you check "intend," indicate the exact nature and duration of the contributions. For example, if you intend to furnish
room and board, state for how long and, if money, state the amount in United States dollars and state whether it is to be
g
iven in a lump sum, weekly or monthly, or for how long.)
Oath or Affirmation of Sponsor
I
acknowled
g
e that I have read Part III o
f
the Instructions, Sponsor and Alien Liabilit
y
, and am aware o
f
m
y
responsibilities as an immigrant sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.
I swear (affirm) that I know the contents of this affidavit signed by me and that the statements are true and correct.
Signature of sponsor
day ofSubscribed and sworn to (affirmed) before me this
at . My commission expires on
S
i
g
nature o
f
O
ff
icer Administerin
g
Oath
Title
If the affidavit is prepared by someone other than the sponsor, please complete the following: I declare that this document
was prepared by me at the request of the sponsor and is based on all information of which I have knowledge.
(Date)(Signature) (Address)
I have life insurance in the sum of
With a cash surrender value of
I own real estate valued at
$
$
$
$
That the following persons are dependent upon me for support: (Place an "x" in the appropriate column to indicate
whether the person named is wholly or partially dependent upon you for support.)
Date submitte
d
,
Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04) Page 2
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signature
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signature
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I-134, Affidavit of Support
Instructions
An alien applying for SSI must make available to the Social
Security Administration documentation concerning his or
her income and resources and those of the sponsor,
including information that was provided in support of the
application for an immigrant visa or adjustment of status.
An alien applying for TANF or Food Stamps must make
similar information available to the State public assistance
agency.
The Secretary of Health and Human Services and the
Secretary of Agriculture are authorized to obtain copies of
any such documentation submitted to the CIS or the U.S.
Department of State and to release such documentation to a
State public assistance agency.
A separate affidavit must be submitted for each person. As
the sponsor, you must sign the affidavit in your full, true
and correct name and affirm or make it under oath.
As the sponsor, you must show you have sufficient income
and/or financial resources to assure that the alien you are
sponsoring will not become a public charge while in the
United States.
Evidence should consist of copies of any or all of the
following documentation listed below that are applicable to
your situation.
Failure to provide evidence of sufficient income and/or
financial resources may result in the denial of the alien's
application for a visa or his or her removal from the United
States.
The sponsor must submit in duplicate evidence of income
and resources, as appropriate:
Sections 1621(e) and 415(d) of the Social Security Act and
subsection 5(i) of the Food Stamp Act also provide that an
alien and his or her sponsor shall be jointly and severally
liable to repay any SSI, TANF or Food Stamp benefits that
are incorrectly paid because of misinformation provided by
a sponsor or because of a sponsor's failure to provide
information.
Incorrect payments that are not repaid will be withheld from
any subsequent payments for which the alien or sponsor
are otherwise eligible under the Social Security Act or Food
Stamp Act, except that the sponsor was without fault or
where good cause existed.
A. Statement from an officer of the bank or other financial
institution where you have deposits, giving the
following details regarding your account:
1. Date account opened;
2. Total amount deposited for the past year;
3. Present balance.
B. Statement of your employer on business stationery,
showing:
1. Date and nature of employment;
2. Salary paid;
3. Whether the position is temporary or permanent.
C. If self-employed:
1. Copy of last income tax return filed; or
2. Report of commercial rating concern.
D. List containing serial numbers and denominations of
b
on
d
s an
d
na
m
e of
r
eco
r
d
owne
r
(
s
)
.
U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Services
I. Execution of Affidavit.
II. Supporting Evidence.
Effective October 1, 1981, amendments to section 415 of the
Social Security Act establish similar requirements for
determining the eligibility of aliens who apply for the first
time for Aid to Families with Dependent Children (AFDC),
currently administered under Temporary Assistance for
N
eedy Families (TANF). Effective December 22, 1981,
amendments to the Food Stamp Act of 1977 affect the
eligibility of alien participation in the Food Stamp Program.
These amendments require that the income and resources of
any person, who as the sponsor of an alien's entry into the
United States, executes an affidavit of support or similar
agreement on behalf of the alien, and the income and
resources of the sponsor's spouse (if living with the
sponsor) shall be deemed to be the income and resources of
the alien under formulas for determining eligibility for SSI,
TANF and Food Stamp benefits during the three years
following the alien's entry into the United States.
Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04)
OMB No. 1615-0014; Exp. 04-30-07
Effective October 1, 1980, amendments to section 1614(f) of
the Social Security Act and Part A of Title XVI of the Social
Security Act establish certain requirements for determining
the eligibility of aliens who apply for the first time for
Supplemental Security Income (SSI) benefits.
III. Sponsor and Alien Liability.
If you are in the United States, the affidavit may be
sworn to or affirmed before an officer of the
Bureau of Citizenship and Immigration Services
(CIS) without the payment of fee, or before a
notary public or other officers authorized to
administer oaths for general purposes, in which
case the official seal or certificate of authority to
administer oaths must be affixed.
If you are outside the United States, the affidavit
must be sworn to or affirmed before a U.S.
consular or immigration officer.
Joint and Several Liability Issues.
Documentation on Income and Resources.
We ask for the information on this form and associated
evidence to determine if you have established eligibility for
the immigration benefit you are seeking. Our legal right to
ask for this information is in 8 U.S.C. 1203 and 1225. We
may provide this information to other government agencies.
Failure to provide this information and any requested
evidence may delay a final decision or result in denial of
your request.
VI. Privacy Act Notice.
It may also, as a matter of routine use, be disclosed to other
federal, state, local and foreign law enforcement and
regulatory agencies, including the Department of Health
and Human Services, Department of Agriculture,
Department of State, Department of Defense and any
component thereof (if the deponent has served or is serving
in the armed forces of the United States), Central
Intelligence Agency, and individuals and organizations
during the course of any investigation to elicit further
information required to carry out CIS functions.
Failure to provide the information may result in the denial of
the alien's application for a visa or his or her removal from
the United States.
Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04) Page 2
V. Information and CIS Forms.
For information on immigration laws, regulations and
procedures or to order CIS forms, call our National
Customer Service Center at 1-800-375-5283 or visit
our website at www.uscis.gov.
An agency may not conduct or sponsor a collection of
information and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. We try to create forms and
instructions that are accurate, can be easily understood and
that impose the least possible burden on you to provide us
with information. Often this is difficult because some
immigration laws are very complex. The estimated average
time to complete and file this application is 30 minutes per
application, including the time to learn about the law and the
form, complete the form, and assemble and submit the
Affidavit. If you have comments regarding the accuracy of
this estimate or suggestions for making this form simpler,
write to the Bureau of Citizenship and Immigration Services,
Regulations and Forms Services Division (HQRFS), 425 I
Street, N.W., Room 4034, Washington, D.C. 20529; OMB
N
o. 1615-0014. Do not mail your completed application to
this address.
VII. Paperwork Reduction Act Notice.
Authority for the collection of the information requested on
this form is contained in 8 U.S.C. 1182(a)(15),1184(a) and
1258.
The information will be used principally by the CIS, or by
any consular officer to whom it may be furnished, to
support an alien's application for benefits under the
Immigration and Nationality Act and specifically the
assertion that he or she has adequate means of financial
support and will not become a public charge. Submission of
the information is voluntary.
IV. Authority, Use and Penalties.
These provisions do not apply to the SSI, TANF or Food
Stamp eligibility of aliens admitted as refugees, granted
asylum or Cuban/ Haitian entrants as defined in section
501(e) of P.L. 96-422, and to dependent children of the
sponsor or sponsor's spouse.
The provisions also do not apply to the SSI or Food Stamp
eligibility of an alien who becomes blind or disabled after
admission to the United States for permanent residency.
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