Fillable I-361 Application for Family Unity Benefits

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I-361 Application for Family Unity Benefits

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The I-361 Application for Family Unity Benefits form is 8 pages long and contains:

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Country of origin: US
File type: PDF

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-361 09/11/15 N Page 1 of 8
Affidavit of Financial Support and Intent to Petition for Legal
Custody of Public Law 97-359 Amerasian
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-361
► START HERE - Type or print in black ink.
Part 1. Information About You (Sponsor)
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. Date of Birth (mm/dd/yyyy)
3.a. City
of Birth
U.S. Social Security Number (if any)5.
►
USCIS ELIS Account Number (if any)6.
►
Physical Address
7.c.
7.d.
7.a.
7.b.
7.g.
7.h.
7.f.
Mailing Address
In Care of Name
A-
►
Alien Registration Number (A-Number) (if any)4.
3.b. Country
of Birth
Information About Citizenship
10. Are you a U.S. citizen? Yes No
How did you acquire your U.S. citizenship?11.
Birth Parents Naturalization
12.a.
If you acquired your U.S. citizenship through your
parents, have you obtained a Certificate of Citizenship in
your own name?
Yes No
If you answered "Yes," provide the following information
about your Certificate of Citizenship:
Name Under Which the Certificate of Citizenship Was
Issued
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
12.c.
Certificate of Citizenship Number
12.d.
12.b.
9.c.
9.d.
9.a.
9.b.
9.g.
9.h.
9.e.
9.i.
8. Are your physical address and mailing address the same?
Yes No
If you answered "No" to Item Number 8., provide your
mailing address in Item Numbers 9.a. - 9.i.
Other
Date of Issuance (mm/dd/yyyy)
12.e. Place of Issuance
City or Town
State 9.f. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Flr.Ste.
City or Town
State 7.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Flr.Ste.
Form I-361 09/11/15 N Page 2 of 8
Part 1. Information About You (Sponsor)
(continued)
Place of Naturalization
If you acquired your U.S. citizenship through naturalization,
provide the following information about your Certificate of
Naturalization:
Name Under Which the Certificate of Naturalization Was
Issued
13.a.
13.b.
Certificate of Naturalization Number
13.c.
Date of Naturalization (mm/dd/yyyy)
13.d.
14. If you acquired your U.S. citizenship through any other
method please provide an explanation. If you need
additional space to complete this section, use the space
provided in Part 8. Additional Information.
Provide the date you started residing in the United States
(mm/dd/yyyy).
15.
A-
►
A-Number (if any)5.
4. Country
of Birth
Marital Status6.
Married
Legally SeparatedWidowed
Single (never married) Divorced
Relationship to Sponsor
7.
Physical Address
8.c.
8.d.
8.a.
8.b.
8.g.
8.h.
8.f.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Part 2. Information About Beneficiary
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
Part 3. Other Information
Employer Address
3.c.
3.d.
3.a.
3.b.
3.g.
3.h.
3.f.
Employment Information
1. Name of Employer
2. Type of Business
2. Date of Birth (mm/dd/yyyy)
Male Female3. Gender
City or Town
State 3.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Flr.Ste.
City or Town
State 8.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Flr.Ste.
Form I-361 09/11/15 N Page 3 of 8
Income Information
If you answered "Yes," attach a copy of your last income
tax return or report of commercial rating concern, which
you certify as true and correct to the best of your
knowledge.
5. Amount deposited in United States banks:
$
6. Value of my other personal property:
7. Market value of my stocks and bonds:
$
$
8.a. Sum of my life insurance policies:
$
8.b. Cash surrender value of my life insurance policies:
$
4.a. My annual income: $
4.b. Are you self-employed?
Yes No
NOTE: Attach a list of stocks and bonds which you
certify as true and correct to the best of your knowledge.
Address 2
11.c.
11.d.
11.a.
11.b.
11.g.
11.h.
11.f.
Dependents Information
The following persons are dependent upon me for support. If
you need additional space for your explanation, use the space
provided in Part 8. Additional Information.
12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)
12.c. Middle Name
9.a. Value of my owned real estate: $
9.b. Amount of mortgages or other debts against my real estate:
$
Address 1
Real Estate Information
NOTE: If you own real estate, provide the physical
addresses in Item Numbers 10.a. - 10.h. If you need
extra space to complete this section, use the space
provided in Part 8. Additional Information.
13.g.
Relationship
Wholly Dependent Partially Dependent
12.g.
Relationship
12.f.
Wholly Dependent Partially Dependent
A-
►
A-Number (if any)12.e.
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c. Middle Name
13.d. Date of Birth (mm/dd/yyyy)
A-
►
A-Number (if any)13.e.
This person is:
This person is:13.f.
Date of Birth (mm/dd/yyyy)12.d.
10.c. City or Town
10.d. State 10.e. ZIP Code
10.f.
Postal Code10.g.
Province
10.h. Country
Street Number
and Name
10.a.
10.b.
Apt. Flr.Ste.
City or Town
State 11.e. ZIP Code
Postal Code
Province
Country
Street Number
and Name
Apt. Flr.Ste.
Form I-361 09/11/15 N Page 4 of 8
Part 3. Other Information (continued)
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c. Middle Name
14.d. Date of Birth (mm/dd/yyyy)
14.g.
Relationship
14.f.
Wholly Dependent Partially Dependent
A-
►
A-Number (if any)14.e.
This person is:
15.a. Family Name
(Last Name)
15.b. Given Name
(First Name)
15.c. Middle Name
15.d. Date of Birth (mm/dd/yyyy)
15.g.
Relationship
15.f.
Wholly Dependent
Partially Dependent
A-
►
A-Number (if any)15.e.
This person is:
17.b. Family Name
(Last Name)
17.c. Given Name
(First Name)
17.d.
Middle Name
If you answered "Yes" to Item Number 16., provide the
responses to Item Numbers 17.a. - 17.f. for each previous
beneficiary. If you need to provide information for more than
one beneficiary, use the space provided in Part 8. Additional
Information.
17.a.
Have you ever submitted or are you submitting affidavits
of support for any other beneficiaries?
16.
A-
►
A-Number (if any)
Yes No
Date of Filing (mm/dd/yyyy)17.e.
Relationship17.f.
19.b. Family Name
(Last Name)
19.c. Given Name
(First Name)
19.d.
Middle Name
Date of Filing (mm/dd/yyyy)19.e.
Relationship19.f.
If you answered "Yes" to Item Number 18., provide the
responses to Item Numbers 19.a. - 19.f. for each previous
beneficiary. If you need to provide information for more than
one beneficiary, use the space provided in Part 8. Additional
Information.
19.a.
Have you ever submitted or are you submitting visa
petitions to USCIS for any other beneficiaries?
18.
A-
►
A-Number (if any)
Part 4. Sponsor's Statement, Contact
Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties
section of the Form I-361 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 have read and
understand every question and instruction on this
affidavit, as well as my answer to every question.
Sponsor's Statement
The interpreter named in Part 5. has also read to me
every question and instruction on this affidavit, as well
as my answer to every question, in
1.b.
a language in which I am fluent. I understand every
question and instruction on this affidavit as translated
to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
,
Yes No
Form I-361 09/11/15 N Page 5 of 8
Part 4. Sponsor's Statement, Contact
Information, Certification, and Signature
(continued)
I have requested the services of and consented to
2.
who is is not an attorney or accredited
representative, preparing this affidavit for me.
,
5.
Sponsor's Email Address (if any)
Sponsor's Mobile Telephone Number (if any)4.
Sponsor's Daytime Telephone Number3.
Sponsor's Contact Information
Sponsor's Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore authorize release of information contained in this
affidavit, in supporting documents, and in my USCIS records,
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I certify:
That this affidavit is made by me to assure the U.S. Government
that the person named in Part 2. Information About
Beneficiary 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. Information About Beneficiary, and
that I agree to furnish financial support during the entire 5-year
period beginning on the date the named person acquires the
status of a lawful permanent resident and ending on the date on
which the named person becomes 21 years of age, whichever
period is longer. The financial support that I furnish is
sufficient to maintain my family, including the named person, in
the United States, at a level equal to at least 125 percent of the
current official poverty line (as established by the Director of
the Office of Management and Budget, under Section 673(2) of
the Omnibus Budget Reconciliation Act of 1981 and as revised
by the Secretary of Health and Human and Services under
section 652 of that Act) for my family size, including the named
person.
That, if the person named in Part 2. Information About
Beneficiary is under 18 years of age, I agree to petition the
court having jurisdiction, within 30 days of the named person's
arrival in the United States, to gain legal custody according to
the laws of the state where he or she will reside until he or she is
18 years of age.
That, if the person named in Part 2. Information About
Beneficiary is under 18 years of age, I agree to pay the interim
costs incurred by that person from the time he or she is released
for immigration by his or her mother or legal guardian until I
am awarded legal custody of him or her.
That, if the person named in Part 2. Information About
Beneficiary is 18 years of age or older, I agree to pay the
interim costs involved in his or her travel to the United States.
That I understand that the Secretary of Homeland Security may
enforce this guarantee of financial support and intent to petition
for legal custody for the person named in Part 2. Information
About Beneficiary against me in a civil suit in the United
States district court of the district in which I reside. However, I
or my estate will not be liable under this guarantee if I die or am
adjudicated as bankrupt under Title 11, United States Code.
That I understand that USCIS may make the information and
documentation provided by me available to the Secretary of
Health and Human Services, the Secretary of Agriculture, or the
Food and Nutrition Service, for use in determination of public
assistance.
That I have read the Form 1-361 Instructions and am aware of
my responsibilities under the Social Security Act as amended,
the Food Stamp Act, and Public Law 97-359.
That under penalty of perjury, that the information in my
affidavit and any document submitted with my affidavit were
provided by me and are complete, true, and correct.
Sponsor's Signature6.a.
6.b. Date of Signature (mm/dd/yyyy)
Sponsor's Signature
NOTE TO ALL SPONSORS: If you do not completely fill
out this affidavit or fail to submit required documents listed in
the Instructions, USCIS may reject your affidavit.
Form I-361 09/11/15 N Page 6 of 8
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 concerning 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.
Apt. Flr.Ste.
Interpreter's Signature6.a.
6.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Affidavit, If Other Than the
Sponsor
Preparer's Full Name
Provide the following information concerning 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.
Interpreter's Daytime Telephone Number
5.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Certification
I certify that:
I am fluent in English and , which
is the same language provided in Part 4., Item Number 1.b.;
I have read to this applicant every question and instruction on
this affidavit, as well as the answer to every question, in the
language provided in Part 4., Item Number 1.b.; and
The applicant has informed me that he or she understands every
instruction and question on the affidavit, as well as the answer
to every question, and the affidavit verified the accuracy of
every answer.
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.
Apt. Flr.Ste.
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Fax Number 5.
Form I-361 09/11/15 N Page 7 of 8
Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Affidavit, If Other Than the
Sponsor (continued)
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 must
submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited
Representative, with this affidavit.
7.a.
7.b.
extends
does not extend beyond the
preparation of this affidavit.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this affidavit on behalf of, at the request
of, and with the express consent of the sponsor. I completed
this affidavit based only on responses the sponsor provided to
me. After completing the affidavit, I reviewed it and all of the
sponsor's responses with the sponsor, who agreed with every
answer on the affidavit. If the sponsor supplied additional
information concerning a question on the affidavit, I recorded it
on the affidavit.
Preparer's Signature
Preparer's Signature8.a.
8.b. Date of Signature (mm/dd/yyyy)
Part 7. Oath of Sponsor
NOTE: Do not sign this portion of the affidavit until you are in
front of a USCIS or Consular Officer.
I swear that the contents of this affidavit were approved by me
and the statements are complete, true, and correct.
Sponsor's Signature
Sponsor's Signature1.a.
1.b. Date of Signature (mm/dd/yyyy)
USCIS or Consular Officer's Signature
USCIS or Consular Officer's Signature3.a.
3.c. Date of Signature (mm/dd/yyyy)
Sponsor's Certification
USCIS or Consulate Certification
This affidavit was subscribed and sworn to in front of me on
this day.
2.a. Date of Affirmation (mm/dd/yyyy)
2.b. Time of Affirmation
USCIS or Consular Officer's Title
3.b.
Form I-361 09/11/15 N Page 8 of 8
Part 8. 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; indicate 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.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
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I-361 Application for Family Unity Benefits

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Completed 16 November 2019

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