I-134, Affidavit Of Support Instructions Page 3
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4OMB No. 1615-0014; Exp. 04-30-07
Department of Homeland Security
I-134, Affidavit of Support
U.S.
Citizenship and Immigration Services
(Answer all items. Type or print in black ink.)
I,
residing at
(Name)
(Street and Number)
(State)
(Zip Code if in U.S.)
(Country)
(City)
Being duly sworn depose and say:
I was born on
at
1.
(Date-mm/dd/yyyy)
(City)
(Country)
If you are not a native born U.S. citizen, answer the following as appropriate:
a. If a U.S.citizen through naturalization, give certificate of naturalization number
b. If a U.S. citizen through parent(s) or marriage, give citizenship certificate number
c. If U.S. 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:
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)
N
ame of spouse and children accompanying or following to join person:
Spouse
Gender
Age
Child
Age
Gender
Gender
Age
Child
Child
Gender
Age
Gender
Age
Gender
Age
Child
Child
4.
That this affidavit is made by me for the purpose of assuring the U.S. 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
5.
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
6.
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
with
(Type of Business)
(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:
Form I-134 (Rev. 07/14/06) Y
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