Form I-134 Affidavit of Support

OMB No. 1615-0014; Exp. 04-30-07

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-134, Affidavit of Support
Instructions

I. Execution of Affidavit.
A separate affidavit must be submitted for each person. As
the sponsor, you must sign the affidavit in your full, true
and correct name and affirm or make it under oath.

B.

Statement of your employer on business stationery,
revealing:
1. Date and nature of employment;
2. Salary paid;
3. Whether the position is temporary or permanent.

If you are in the United States, the affidavit may be
sworn to or affirmed before an officer of U.S.
Citizenship and Immigration Services (USCIS)
without the payment of fee, or before a notary public
or other officers authorized to administer oaths for
general purposes, in which case the official seal or
certificate of authority to administer oaths must be
affixed.

C. If self-employed:

If you are outside the United States, the affidavit
must be sworn to or notice affirmed before a U.S.
consular or immigration officer.

Effective October 1, 1980, amendments to section 1614(f) of
the Social Security Act and Part A of Title XVI of the Social
Security Act establish certain requirements for determining
the eligibility of aliens who apply for the first time for
Supplemental Security Income (SSI) benefits.

How you submit the form depends on whether the alien
you are sponsoring is in or outside the United States and
what type of application is being submitted. See the
instructions provided with the corresponding application
for detailed information on how to submit this affidavit of
support form.

II. Supporting Evidence.
As the sponsor, you must show you have sufficient income
and/or financial resources to assure that the alien you are
sponsoring will not become a public charge while in the
United States.
Evidence should consist of copies of any or all of the
following documentation listed below that are applicable to
your situation.
Failure to provide evidence of sufficient income and/or
financial resources may result in the denial of the alien's
application for a visa or his or her removal from the United
States.
The sponsor must submit in duplicate evidence of income
and resources, as appropriate:
A. Statement from an officer of the bank or other financial
institutions where you have deposits, identifying the
following details regarding your account:
1. Date account opened;
2. Total amount deposited for the past year;
3. Present balance.

1. Copy of last income tax return filed; or
2. Report of commercial rating concern.
D. List containing serial numbers and denominations of
bonds and name of record owner(s).

III. Sponsor and Alien Liability.

Effective October 1, 1981, amendments to section 415 of the
Social Security Act established similar requirements for
determining the eligibility of aliens who apply for the first
time for Aid to Families with Dependent Children (AFDC),
currently administered under Temporary Assistance for
Needy Families (TANF). Effective December 22, 1981,
amendents to the Food Stamp Act of 1977 affect the
eligibility of alien participants in the Food Stamp Program.
These amendments require that the income and resources of
any person who, as the sponsor of an alien's entry into the
United States, executes an affidavit of support or similar
agreement on behalf of the alien, and the income and
resources of the sponsor's spouse (if living with the
sponsor) shall be deemed to be the income and resources of
the alien under formulas for determining eligibility for SSI,
TANF and Food Stamp benefits during the three years
following the alien's entry into the United States.
Documentation on Income and Resources.
An alien applying for SSI must make available to the Social
Security Administration documentation concerning his / her
income and resources and those of the sponsor, including
information that was provided in support of the
corresponding application.
An alien applying for TANF or Food Stamps must make
similar information available to the State public assistance
agency.
The Secretary of Health and Human Services and the
Secretary of Agriculture are authorized to obtain copies of
any such documentation submitted to USCIS or the U.S.
Department of State and to release such documentation to a
State public assistance agency.

Form I-134 (Rev. 12/04/06)Y

Joint and Several Liability Issues.
Sections 1621(e) of the Social Security Act and
subsection 5(i) of the Food Stamp Act also provide that an
alien and his or her sponsor shall be jointly and severally
liable to repay any SSI, TANF or Food Stamp benefits that
are incorrectly paid because of misinformation provided
by a sponsor or because of a sponsor's failure to provide
information, except where the sponsor was without fault or
where good cause existed.
Incorrect payments that are not repaid will be withheld from
any subsequent payments for which the alien or sponsor are
otherwise eligible under the Social Security Act or Food
Stamp Act.
These provisions do not apply to SSI, TANF or Food
Stamp eligibility of aliens admitted as refugees, granted
asylum or Cuban/ Haitian entrants as defined in section
501(e) of P.L. 96-422, and to dependent children of the
sponsor or sponsor's spouse.

IV. Information and USCIS Forms.
For information on immigration laws, regulations and
procedures or to order USCIS forms, call our National
Customer Service Center at 1-800-375-5283 or visit our
website at www.uscis.gov.

V. Use InfoPass for Appointments.
As an alternative to waiting in line for assistance at your local
USCIS office, you can now schedule an appointment through
our Internet-based system, InfoPass. To access the system,
visit our website at www.uscis.gov. Use the InfoPass
appointment scheduler and follow the screen prompts to set
up your appointment. InfoPass generates an electronic
appointment notice that appears on the screen. Print the
notice and take it with you to your appointment. The notice
gives the time and date of your appointment, along with the
address of the USCIS office.

VI. Privacy Act Notice.
We ask for the information on this form and associated
evidence to determine if you have established eligibility for
the immigration benefit you are seeking. We may provide
this information to other government agencies. Failure to
provide this information and any requested evidence may
delay a final decision or result in denial of your request.

The information will be used principally by USCIS, or by
any consular officer to whom it may be furnished, to support
an alien's application for benefits under the Immigration and
Nationality Act and specifically the assertion that he or she
has adequate means of financial support and will not become
a public charge. Submission of the information is voluntary.
However, failure to provide the information may result in
the denial of the alien's application.
The information may also as a matter of routine use be
disclosed to other federal, state, local and foreign law
enforcement and regulatory agencies, including the
Department of Health and Human Services, Department of
Agriculture, Department of State, Department of Defense
and any component thereof (if the deponent has served or
is serving in the armed forces of the United States), Central
Intelligence Agency, and individuals and organizations
during the course of any investigation to elicit further
information required to carry out USCIS functions.

VII. Paperwork Reduction Act Notice.
You are not required to respond to this form unless it
displays a currently valid OMB control number.
We try to create forms and instructions that are accurate,
can be easily understood and impose the least possible
burden on you to provide us with information. Often this
is difficult because some immigration laws are very
complex.
The estimated average time to complete and file this
notice is 90 minutes.
If you have comments regarding the accuracy of this
estimate, or suggestions for making this form simpler,
you may write to: U.S. Citizenship and Immigration
Services, Regulatory Management Division, 111
Massachusetts Avenue, N.W., 3rd Floor, Suite 3008,
Washington, DC 20529; OMB No. 1615-0014. Do not
mail your completed affidavit of support to this
address.

Authority for the collection of the information requested on
this form is contained in 8 U.S.C. 1182(a)(4),1183(a),1184
(a) and 1258.

Form I-134 (Rev. 12/04/06)Y Page 2

OMB No. 1615-0014; Exp. 04-30-07

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-134, Affidavit of Support
(Answer all items. Type or print in black ink.)

I,

residing at
(Name)

(Street and Number)
(State)

(City)

(Zip Code if in U.S.)

(Country)

Being duly sworn depose and say:
at

1. I was born on

(Country)

(Date-mm/dd/yyyy)
(City)
If you are not a native born U.S. citizen, answer the following as appropriate:
a. If a U.S.citizen through naturalization, give certificate of naturalization number
b. If a U.S. citizen through parent(s) or marriage, give citizenship certificate number
c. If U.S. 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. I am

years of age and have resided in the United States since (date)

3. This affidavit is executed on behalf of the following person:
Name

(Family Name)

(First Name)

(Middle Name)

Citizen of (Country)

Marital Status

Presently resides at (Street and Number)

(City)

Gender

Age

Relationship to Sponsor
(State)

(Country)

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

Gender

Age

Child

Gender

Age

Child

Gender

Age

Child

Gender

Age

Child

Gender

Age

Child

Gender

Age

4. This affidavit is made by me for the purpose of assuring the U.S. Government that the person(s) named in
item (3) will not become a public charge in the United States.
5. 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 person(s) 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. 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.

with

7. I am employed as or engaged in the business of

(Name of Concern)

(Type of Business)

at
(Street and Number)

(City)

(State)

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 instructions 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:

$

(Zip Code)

Form I-134 (Rev. 12/04/06) Y

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 mortgage(s) or other encumbrance(s) thereon amounting to: $

$
$

Which is located at:
(Street and Number)
(City)
(State)
8. The following persons are dependent upon me for support: (Place an "x" in the appropriate column to indicate
whether the person named is wholly or partially dependent upon you for support.)

Name of Person

Wholly Dependent

Partially Dependent

Age

(Zip Code)

Relationship to Me

9. I have previously submitted affidavit(s) of support for the following person(s). If none, state none.
Name

Date submitted

10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services (USCIS) on behalf of the
following person(s). If none, state none.
Relationship
Name

Date submitted

11. I
intend
do not intend to make specific contributions to the support of the person(s) named in item 3.
(If you check "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 U.S. dollars and state whether it is to be given in a lump
sum, weekly or monthly, and for how long.

Oath or Affirmation of Sponsor.
I acknowledge that I have read Part lll of the Instructions, Sponsor and Alien Liability, and am aware of my responsibilities
as a 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 that the statements are true and correct.
Signature of sponsor
Subscribed and sworn to (affirmed) before me this
at

,

day of
.

My commission expires on
Title

Signature of Officer Administering Oath

If the affidavit is prepared by someone other than the sponsor, please complete the following: I declare that this document
was prepared by me at the request of the sponsor and is based on all information of which I have knowledge.
(Signature)

(Address)

(Date)
Form I-134 (Rev. 12/04/06)YPage 2