OMB No. 1115-0062
Affidavit of Su
pp
ort
(Answer All Items: Fill in with Typewriter or Print in Block Letters in Ink.)
residing at
I,
(
Street and Number
)
(
Name
)
(Zip Code if in U.S.)(City)
1. I was born on
(Country)
(
Date
)
(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 in behalf of the following person:
Gender Age
N
ame
Citizen of (Country) Relationship to SponsorMarital 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 Gender Age
Child Gender Age
Child Gender Age
4.
5.
6.
with7. That 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
I have other personal property, the reasonable value of which is
$
OVER
U.S. Department of Justice
Immigration and Naturalization Service
(
Countr
y)
(
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.
$
$
Form I-134 (Rev. 10/12/00)Y
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. That I have previously submitted affidavit(s) of support for the following person(s). If none, state
"None.''
ame
10. That I have submitted visa petition(s) to the Immigration and Naturalization Service on behalf of the following
person(s). If none, state none.
Date submittedRelationshi
p
N
ame
11.
(Complete this block only if the person named in the item 3 will be in the United States temporarily.)
That I intend do not intend, to make specific contributions to the support of the person 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 given in a lump sum, weekly or monthly, or for how long.)
Oath or Affirmation of S
p
onsor
l acknowledge at that l have read Part III of the Instructions, Sponsor and Alien Liability, and am aware of my
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 the statements are true and correct.
Signature of sponsor
day ofSubscribed and sworn to (affirmed) before me this
at . My commission expires on
Signature of Officer Administering Oath
Title
If affidavit prepared by other than 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 submitted
,
Form I-134 (Rev. 10/12/00)Y Page 2
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 AFDC 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 INS or the
Department of State and to release such documentation to a
State public assistance agency.
I. Execution of Affidavit.
A separate affidavit must be submitted for each person.
You, as the sponsor, must sign the affidavit in your full,
true and correct name and affirm or make it under oath. If
you are in the United States, the affidavit may be sworn to
or affirmed before an immigration officer without the
payment of fee, or before a notary public or other officer
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 United States consular or immigration officer.
II. Supporting Evidence.
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 severably
liable to repay any SSI, AFDC 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 in which you have deposits giving the
following details regarding your account:
1. date account opened
B. Statement of your employer on business stationery,
showing:
1. date and nature of employment
These provisions do not apply to the SSI, AFDC or Food
Stamp eligibility of aliens admitted as refugees, granted
political asylum by the Attorney General, or Cuban/ Haitian
entrants as defined in section 501(e) of P.L. 96-422 and of
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.
2. salary paid
3. whether position is temporary or permanent
C. If self-employed:
1. copy of last income tax return filed, or
D. List containing serial numbers and denominations of
bonds and name of record owner(s).
IV. Authority/ Use/ Penalties.
Authority for the collection of the information requested
on this form is contained in 8 USC 1182(a)(15),1184(a)
and 1258. The information will be used principally by INS,
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. 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 Service 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.
III. Sponsor and Alien Liability.
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.
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)
benefits. 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, AFDC and Food Stamp benefits during the three years
following the alien's entry into the United States.
(Please tear off this sheet before submitting Affidavit)
U.S. Department of Justice
Immigration and Naturalization Service
2. total amount deposited for the past year
3. present balance
2. report of commercial rating concern
Form I-134 Instructions (Rev. 10/12/00)Y
Privacy Act Notice.
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 USC 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.
Paperwork Reduction Act Notice.
We try to create forms and instructions that are accurate, can be
easily understood and which 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 20
minutes per application. If you have comments regarding the
accuracy of this estimate or suggestions for making this form
simpler, you can write to the Immigration and Naturalization
Service, HQPDI, 425 I Street, N.W., Room 4034, Washington,
D.C. 20536; OMB No. 1115-0005.
DO NOT MAIL YOUR
COMPLETED APPLICATION TO THIS ADDRESS.
Form I-134 Instructions (Rev. 10/12/00)Y, Page 2