I-134, Affidavit Of Support - Nice (Page 2 of 4) in pdf

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 and Number)

(City)

(State)

(Zip Code)

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

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

Name

Date submitted

10. 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

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

. 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)

Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04) Page 2

I-134, Affidavit Of Support - Nice Page 2

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