Fillable Affidavit Of Support Form (Page 2 of 2) in pdf

Affidavit Of Support Form Page 2

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7. I am employed as or engaged in the business of

with

(Type of Business)

(Name of Concern)

(State)

(Street Number and Name

(City)

(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 of 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:

(Street Number and Name)

(City)

(State)

(Zip Code)

8. The following persons are dependent upon me for support: (Check the box 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

9. I have previously submitted affidavit(s) of support for the following person(s). If none, state "None".

Name of Person

Date submitted

10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services on behalf of the following person(s). If none, state "None".

Name of Person

Relationship

Date submitted

do not intend to make specific contributions to the support of the person(s) named in item 3.

11. I

intend

(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 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 "Sponsor and Alien Liability" on Page 2 of the instructions for this form, and am aware of my

responsibilities as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.

I certify under penalty of perjury under United States law that I know the contents of this affidavit signed by me and that the statements are

true and correct.

Signature of Sponsor

Date

Form I-134 02/19/14 Y Page 2

Affidavit Of Support Form Page 2

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