Affidavit Of Support Form I-134 printable pdf download

U.S. Department of Justice

Affidavit of Support

Immigration and Naturalization Service

INSTRUCTIONS

I. EXECUTION OF AFFIDAVIT. A separate affidavit must be

An alien applying for SSI must make available to the Social Secu-

submitted for each person. You must sign the affidavit in your full,

rity Administration documentation concerning his or her income

true and correct name and affirm or make it under oath. If you are

and resources and those of the sponsor including information which

in the United States the affidavit may be sworn or affirmed be-

was provided in support of the application for an immigrant visa

fore an immigration officer without the payment of fee, or before

or adjustment of status. An alien applying for AFDC or Food Stamps

a notary public or other officer authorized to administer oaths for

must make similar information available to the State public assis-

general purposes, in which case the official seal or certificate of

tance agency. The Secretary of Health and Human Services and

authority to administer oaths must be affixed. If you are outside

the Secretary of Agriculture are authorized to obtain copies of any

the United States the affidavit must be sworn to or affirmed be-

such documentation submitted to INS or the Department of State

fore a United States consular or immigration officer.

and to release such documentation to a State public assistance

agency.

II. SUPPORTING EVIDENCE. The deponent must submit in

duplicate evidence of income and resources, as appropriate:

Sections 1621(e) and 415(d) of the Social Security Act and sub-

section 5(i) of the Food Stamp Act also provide that an alien and

A. Statement from an officer of the bank or other financial insti-

his or her sponsor shall be jointly and severably liable to repay any

tution in which you have deposits giving the following de-

SSI, AFDC, or Food Stamp benefits which are incorrectly paid

tails regarding your account:

because of misinformation provided by a sponsor or because of a

1. Date account opened.

sponsor’s failure to provide information. Incorrect payments which

2. Total amount deposited for the past year (in U.S. dollars).

are not repaid will be withheld from any subsequent payments for

3. Present balance.

which the alien or sponsor are otherwise eligible under the Social

Security Act or Food Stamp Act, except that the sponsor was with-

B. Statement of your employer on business stationery, showing:

out fault or where good cause existed.

1. Date and nature of employment.

2. Salary paid (in U.S. dollars).

These provisions do not apply to the SSI, AFDC, or Food Stamp

3. Whether position is temporary or permanent.

eligibility of aliens admitted as refugees, granted political asylum

by the Attorney General, or Cuban/Haitian entrants as defined in

C. If self-employed:

section 501(e) of P.L. 96-422 and of dependent children of the

1. Copy of last income tax return filed or,

sponsor or sponsor’s spouse. They also do not apply to the SSI or

2. Report of commercial rating concern.

Food Stamp eligibility of an alien who becomes blind or disabled

after admission into the United States for permanent residency.

D. List containing serial numbers and denominations of bonds

and name of record owner(s).

IV. AUTHORITY/USE/PENALTIES. Authority for the

collection of the information requested on this form is contained

III. SPONSOR AND ALIEN LIABILITY. Effective October 1,

is 8 U.S.C. 1182(a) (15), 1184(a), and 1258. The information

1980, amendments to section 1614(f) of the Social Security Act

will be used principally by the Service, or by any consular

and Part A of Title XVI of the Social Security Act establish certain

officer to whom it may be furnished, to support an alien’s

requirements for determining the eligibility of aliens who apply

application for benefits under the Immigration and Nationality

for the first time for Supplemental Security Income (SSI) benefits.

Act and specifically the assertion that he or she has adequate

Effective October 1, 1981, amendments to section 415 of the So-

means of financial support and will not become a public charge.

cial Security Act establish similar requirements for determining

Submission of the information is voluntary. It may also, as a

the eligibility of aliens who apply for the first time for Aid to Fami-

matter of routine use, be disclosed to other federal, state, local

lies with Dependent Children (AFDC) benefits. Effective Decem-

and foreign law enforcement and regulatory agencies, including

ber 22, 1981, amendments to the Food Stamp Act of 1977 affect

the Department of Health and Human Services, the Department

the eligibility of alien participation in the Food Stamp Program.

of Agriculture, the Department of State, the Department of

These amendments require that the income and resources of any

Defense and any component thereof (if the deponent has served

person who, as the sponsor of an alien’s entry into the United States,

or is serving in the armed forces of the United States), the

executes an affidavit of support or similar agreement on behalf of

Central Intelligence Agency, and individuals and organizations

the alien, and the income and resources of the sponsor’s spouse (if

during the course of any investigation to elicit further informa-

living with the sponsor) shall be deemed to be the income and

tion required to carry out Service functions. Failure to provide

resources of the alien under formulas for determining eligibility

the information may result in the denial of the alien’s application

for SSI, AFDC, and Food Stamp benefits during the three years

for a visa, or his or her exclusion from the United States.

following the alien’s entry into the United States.

Form I-134 (Rev. 12-1-84) Y

Affidavit Of Support Form I-134

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