Form I-361 - Affidavit Of Financial Support And Intent To Petition For Legal Custody For Public Law 97-359 Amerasian Page 3

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Address 2
Income Information
11.a.
Street Number
4.a. My annual income:
$
and Name
11.b.
Apt.
Ste.
Flr.
4.b. Are you self-employed?
Yes
No
11.c.
City or Town
If you answered "Yes," attach a copy of your last income
tax return or report of commercial rating concern, which
11.d.
State
11.e. ZIP Code
you certify as true and correct to the best of your
knowledge.
11.f.
Province
5.
Amount deposited in United States banks:
$
11.g.
Postal Code
6.
Value of my other personal property:
11.h.
Country
$
7.
Market value of my stocks and bonds:
Dependents Information
$
The following persons are dependent upon me for support. If
NOTE: Attach a list of stocks and bonds which you
you need additional space for your explanation, use the space
certify as true and correct to the best of your knowledge.
provided in Part 8. Additional Information.
8.a. Sum of my life insurance policies:
12.a. Family Name
$
(Last Name)
12.b. Given Name
8.b. Cash surrender value of my life insurance policies:
(First Name)
$
12.c. Middle Name
Real Estate Information
12.d.
Date of Birth (mm/dd/yyyy)
12.e.
A-Number (if any)
9.a. Value of my owned real estate: $
►
A-
NOTE: If you own real estate, provide the physical
addresses in Item Numbers 10.a. - 10.h. If you need
12.f.
This person is:
extra space to complete this section, use the space
Wholly Dependent
Partially Dependent
provided in Part 8. Additional Information.
12.g. Relationship
9.b. Amount of mortgages or other debts against my real estate:
$
Address 1
13.a. Family Name
10.a.
Street Number
(Last Name)
and Name
13.b. Given Name
10.b.
Apt.
Ste.
Flr.
(First Name)
13.c. Middle Name
10.c. City or Town
13.d. Date of Birth (mm/dd/yyyy)
10.d. State
10.e. ZIP Code
13.e.
A-Number (if any)
10.f.
Province
►
A-
10.g.
Postal Code
13.f.
This person is:
Wholly Dependent
Partially Dependent
10.h. Country
13.g. Relationship
Form I-361 09/11/15 N
Page 3 of 8

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