Affidavit Of Support Form I-134 (Page 3 of 3) 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 mortgages or other encumbrances thereon amounting to $____________________________________

Which is located at _______________________________________________________________________________________________________

(Street and Number)

(City)

(State)

(ZIP Code)

8. 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 and partially dependent upon you for support.)

Name of Person

Wholly Dependent

Partially Dependent

Age

Relationship to Me

__________________________________________________________________________________________________________________________________________________________

9. That I have previously submitted af•idavit(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 Immigration and Naturalization Service on behalf of the following person(s). If none, state “None.)

Name

Relationship

Date Submitted

__________________________________________________________________________________________________________________________________________________________

11. (Complete this block only if the person named in item 3 will be in the United States temporarily.)

That I

do intend

do not intend to make specific contributions to the support of the person named in item 3. (If you check “do 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 DEPONENT

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 the statements are true and correct.

Signature of deponent ________________________________________________________________________________________________________

Subscribed and sworn to (affirmed) before me this ________________ day of ___________________________________________, 20_______________

at _____________________________________________________________ My commission expires on ___________________________________

Signature of Officer Administering Oath ___________________________________________________ Title __________________________________

If affidavit prepared by other than deponent, please complete the following: I declare that this document was prepared by me at the request of the

deponent and is based on all information of which I have knowledge.

__________________________________________________________________________________________________________________________________________________________

(Signature)

(Address)

Affidavit Of Support Form I-134 Page 3

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