I-134, Affidavit of Support (United States)
This form is to sponsor to support an alien. The form provided here is simply a sample of what the actual Form I-134 looks like.
Department of Homeland Security
Bureau of Citizenship and Immigration Services
I-134, Affidavit of Support
(Answer All Items: Type or Print in Black Ink.)
I, _______________________________ (Name)
residing at _______________________________ (Street and Number)
_______________________________ (City)
_______________________________ (State)
_______________________________ (Zip Code if in U.S.)
_______________________________ (Country)
BEING DULY SWORN DEPOSE AND SAY:
1. I was born on _______________________________ (Date-mm/dd/yyyy)
at _______________________________ (City)
_______________________________ (Country)
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:
1. Name (Family name) _______________________________
(First Name) _______________________________
(Middle Name) _______________________________
Gender ____________________
Age _________________
Citizen of (Country) _______________________________
Marital Status _______________________________
Relationship to Sponsor _______________________________
Presently resides at (Street and Number) _______________________________
(City) _______________________________
(State) _______________________________
(Country) _______________________________
Name of spouse and children accompanying or following to join person:
Spouse _______________________________
Gender ____________________
Age _________________
Child _______________________________
Gender ____________________
Age _________________
Child _______________________________
Gender ____________________
Age _________________
Child _______________________________
Gender ____________________
Age _________________
4. 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.
5. 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.
6. 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.
7. That I am employed as or engaged in the business of _______________________________ (Type of Business)
with _______________________________ (Name of Concern)
at _______________________________ (Street and Number)
_______________________________ (City)
_______________________________ (State)
_______________________________ (Zip Code)
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 $________________________
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. $__________________________
I have life insurance in the sum of $_______________________________
With a cash surrender value of $_______________________________
I own real estate valued at $_______________________________
With mortgage(s) or other encumbrance(s) thereon amounting to $_______________________________
Which is located at _______________________________ (Number and Street)
_______________________________ (City)
_______________________________ (State)
_______________________________ (Zip Code)
8. 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.)
Name of Person _______________________________
Wholly Dependent _______________________________
Partially Dependent _______________________________
Age _______
Relationship to Me _______________________________
Name of Person _______________________________
Wholly Dependent _______________________________
Partially Dependent _______________________________
Age _______
Relationship to Me _______________________________
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.''
Name _______________________________
Date Submitted _______________________________
Name _______________________________
Date Submitted _______________________________
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.
Name _______________________________
Relationship _______________________________
Date Submitted _______________________________
Name _______________________________
Relationship _______________________________
Date Submitted _______________________________
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 given in a lump sum, weekly or monthly, or for how long.)
_______________________________
Oath or Affirmation of Sponsor
I acknowledge that I 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 that the statements are true and correct.
Signature of sponsor _______________________________
Subscribed and sworn to (affirmed) before me this __________________ day of _____________
At _______________________________.
My commission expires on _______________________________
Signature of Officer Administering 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.
(Signature) _______________________________
(Address) _______________________________
(Date) _______________________________