I-134, Affidavit of Support
Instructions
An alien applying for SSI must make available to the Social
Security Administration documentation concerning his / her
income and resources and those of the sponsor, including
information that was provided in support of the corresponding
application.
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:
A. Statement from an officer of the bank or other financial
institutions where you have deposits, identifying the
following details regarding your account:
1. Date account opened;
B. Statement of your employer on business stationery,
revealing:
1. Date and nature of employment;
C. If self-employed:
2. Report of commercial rating concern.
D. List containing serial numbers and denominations of
bonds and name of record owner(s).
I. Execution of Affidavit.
II. Supporting Evidence.
Effective October 1, 1981, amendments to section 415 of the
Social Security Act established 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 Needy
Families (TANF). Effective December 22, 1981, amendents 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. 02/28/07)Y
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 U.S. Citizenship
and Immigration Services (USCIS) 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 notice affirmed before a U.S.
consular or immigration officer.
Documentation on Income and Resources.
Department of Homeland Security
U.S. Citizenship and Immigration Services
How you submit the form depends on whether the alien you
are sponsoring is in or outside the United States and what type
of application is being submitted. See the instructions
provided with the corresponding application for detailed
information on how to submit this affidavit of support form.
2. Total amount deposited for the past year;
3. Present balance.
2. Salary paid;
3. Whether the position is temporary or permanent.
1. Copy of last income tax return filed; or
The information 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 USCIS functions.
However, failure to provide the information may result in the
denial of the alien's application.
Form I-134 (Rev. 02/28/07)Y Page 2
IV. Information and USCIS Forms.
For information on immigration laws, regulations and
procedures or to order USCIS forms, call our National
Customer Service Center at 1-800-375-5283 or visit our
website at www.uscis.gov.
VII. Paperwork Reduction Act Notice.
The information will be used principally by USCIS, 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.
These provisions do not apply to 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.
As an alternative to waiting in line for assistance at your local
USCIS office, you can now schedule an appointment through
our internet-based system, InfoPass. To access the system,
visit our website at www.uscis.gov. Use the InfoPass
appointment scheduler and follow the screen prompts to set up
your appointment. InfoPass generates an electronic
appointment notice that appears on the screen. Print the notice
and take it with you to your appointment. The notice gives the
time and date of your appointment, along with the address of
the USCIS office.
V. Use InfoPass for Appointments.
You are not required to respond to this form unless it displays
a currently valid OMB control number.
Joint and Several Liability Issues.
Sections 1621(e) 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 mis-information provided by a
sponsor or because of a sponsor's failure to provide
information, except where the sponsor was without fault or
where good cause existed.
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.
The Secretary of Health and Human Services and the
Secretary of Agriculture are authorized to obtain copies of
any such documentation submitted to USCIS or the U.S.
Department of State and to release such documentation to a
State public assistance agency.
An alien applying for TANF or Food Stamps must make
similar information available to the State public assistance
agency.
Authority for the collection of the information requested on
this form is contained in 8 U.S.C. 1182(a)(4),1183(a),1184(a)
and 1258.
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. 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.
We try to create forms and instructions that are accurate, can
be easily understood and 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 notice is
15 minutes.
If you have comments regarding the accuracy of this estimate,
or suggestions for making this form simpler, you may write to:
U.S. Citizenship and Immigration Services, Regulatory
Management Division, 111 Massachusetts Avenue, N.W., 3rd
Floor, Suite 3008, Washington, DC 20529. Do not mail your
completed affidavit of support to this address.
OMB No. 1615-0014; Exp. 04-30-07
I-134, Affidavit of Support
(Answer all items. Type or print in black ink.)
1. I was born on
(City)
If you are not a native born U.S. citizen, 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 lawfully admitted permanent resident of the United States, give "A" number
2. I am
years of age and have resided in the United States since (date)
3. This affidavit is executed on behalf of the following person:
Gender
Age
(Middle Name)
Citizen of (Country) Relationship to Sponsor
Marital Status
Presently resides at (Street and Number) (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.
5.
6.
with
7. I am employed as or engaged in the business of
(Name of Concern)
(Type 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:
$
Department of Homeland Security
U.S. Citizenship and Immigration Services
at
Being duly sworn depose and say:
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.
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.
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.
$
$
Gender
Gender
Age
(Date-mm/dd/yyyy)
Form I-134 (Rev. 02/28/07) Y
(Country)
I have other personal property, the reasonable value of which is:
b. If a U.S. citizen through parent(s) or marriage, give citizenship certificate number
Name (Family Name) (First Name)
residing at
I,
(Street and Number)
(Name)
(Zip Code if in U.S.) (Country)(State)
(City)
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)
(City) (State)(Street and Number)
8.
Name of Person
Wholly Dependent Partially Dependent Age Relationship to Me
9. I have previously submitted affidavit(s) of support for the following person(s). If none, state none.
Name
10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services (USCIS) on behalf of the
following person(s). If none, state none.
Date submitted
Relationship
Name
11. 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 U.S. dollars and state whether it is to be given in a lump
sum, weekly or monthly, and for how long.
Oath or Affirmation of Sponsor.
I acknowledge that I have read Part lll of the Instructions, Sponsor and Alien Liability, and am aware of my responsibilities
as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.
Signature of sponsor
day ofSubscribed and sworn to (affirmed) before me this
at . My commission expires on
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:
I own real estate valued at:
$
$
$
$
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 submitted
,
Form I-134 (Rev. 02/28/07)YPage 2
I swear (affirm) that I know the contents of this affidavit signed by me and that the statements are true and correct.
Signature of Officer Administering Oath
With a cash surrender value of:
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