Affidavit Of Support Form I-134 (Page 2 of 3) in pdf

U.S. Department of Justice

Affidavit of Support

Immigration and Naturalization Service

(ANSWER ALL ITEMS: FILL IN WITH TYPEWRITER OR PRINT IN BLOCK LETTERS IN INK.)

I, ______________________________________________ residing at___________________________________________________________________

(Name)

(Street and Number)

_______________________________________________________________________________________________________________________________________

(City)

(State)

(ZIP Code if in U.S.)

(Country)

BEING DULY SWORN DEPOSE AND SAY:

1. I was born on ________________________ at ___________________________________________________________________________________

(Date)

(City)

(Country)

If you are not a native born United States citizen, answer the following as appropriate:

a. If a United States citizen through naturalization, give certificate of naturalization number _______________________________________________

b. If a United States citize through parent(s) or marriage, give citizenship certificate number _______________________________________________

c. If United States 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 in behalf of the following person:

Name

Sex

Age

Citizen of–(Country)

Marital Status

Relationship to Deponent

Presently resides at–(Street and Number)

(City)

(State)

(Country)

Name of spouse and children accompanying or following to join person:

Spouse

Sex

Age

Child

Sex

Age

Child

Sex

Age

Child

Sex

Age

Child

Sex

Age

Child

Sex

Age

4. That this affidavit is made by me for the purpose of assuring the United States Government that the person(s) named in item 3 will not become a

public charge in the United States.

5. 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 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 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.

6. 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 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 instruction 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 of which is

$___________________________

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

Affidavit Of Support Form I-134 Page 2

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