Form I-134 - Affidavit Of Support Page 2
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8Part 1. Information About You (the Sponsor)
Beneficiary's Physical Address
(continued)
8.a.
Street Number
and Name
11.c.
I derived my U.S. citizenship by another method.
(Provide an explain in Part 7. Additional
8.b.
Apt.
Ste.
Flr.
Information.)
8.c.
City or Town
11.d.
I am a lawful permanent resident of the
United States. My A-Number is
8.d.
State
8.e. ZIP Code
►
A-
8.f.
Province
11.e.
I am a lawfully admitted nonimmigrant. My
Form I-94, Arrival-Departure Record Number is
8.g.
Postal Code
►
8.h.
Country
12.
I am
years of age and have resided in the United
States since (Date) (mm/dd/yyyy)
Beneficiary's Spouse (accompanying or following
to join beneficiary)
Part 2. Information About the Beneficiary
9.a. Family Name
This affidavit is executed on behalf of the following person:
(Last Name)
1.a. Family Name
9.b. Given Name
(Last Name)
(First Name)
1.b. Given Name
9.c. Middle Name
(First Name)
1.c. Middle Name
10.
Date of Birth (mm/dd/yyyy)
2.
Date of Birth (mm/dd/yyyy)
11.
Gender
Male
Female
3.
Gender
Male
Female
Beneficiary's Children
4.
A-Number (if any)
Child 1
►
A-
12.a. Family Name
(Last Name)
5.
Country of Citizenship or Nationality
12.b. Given Name
(First Name)
6.
Marital Status
12.c. Middle Name
Single or Single, Never Married
13.
Date of Birth (mm/dd/yyyy)
Married
Divorced
14.
Gender
Male
Female
Widowed
Child 2
Legally Separated
15.a. Family Name
Marriage Annulled
(Last Name)
15.b. Given Name
Other
(First Name)
Relationship to Sponsor
7.
15.c. Middle Name
16.
Date of Birth (mm/dd/yyyy)
17.
Gender
Male
Female
If you need additional space to complete this section, use the
space provided in Part 7. Additional Information.
Form I-134 11/30/16 N
Page 2 of 8
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