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
