Form I-134 Affidavit of Support

OMB No. 1615-0014; Expires 05/31/2012

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

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

I,
(Name)

(Street Number and Name)
-

(State)

(City)

(Zip Code if in U.S.)

(Country)

(State)

(Country)

certify under penalty of perjury under U.S. law, that:
in

1. I was born on
(Date-mm/dd/yyyy)

(City)

If you are not a U.S. citizen based on your birth in the United States, or a non-citizen U.S. national based on your birth in American Samoa (including
Swains Island), 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 Certificate of Citizenship number
c. If U.S. citizenship was derived by some other method, attach a statement of explanation.
d. If a Lawful Permanent Resident of the United States, give A-Number
e. If a lawfully admitted nonimmigrant, give Form I-94, Arrival-Departure Record, number
2. I am

years of age and have resided in the United States since
(Date-mm/dd/yyyy)

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

(Family Name)

(First Name)

(Middle Name)
Marital Status

Citizen of (Country)
Presently resides at (Street Number and Name)

(City)

Age

Relationship to Sponsor
(State)

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

Gender

(Country)

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. 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 that:
a. Form I-134 is an “undertaking” under section 213 of the Immigration and Nationality Act, and I may be sued if the person(s) named in item 3
becomes a public charge after admission to the United States;
b. Form I-134 may be made available to any Federal, State, or local agency that may receive an application from the person(s) named in item 3
for Food Stamps, Supplemental Security Income, or Temporary Assistance to Needy Families; and
c. If the person(s) named in item 3 does apply for Food Stamps, Supplemental Security Income, or Temporary Assistance for Needy Families,
my own income and assets may be considered in deciding the person's application. How long my income and assets may be attributed to the
person(s) named in item 3 is determined under the statutes and rules governing each specific program.
Form I-134 (Rev. 05/25/11) Y

with

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

(Name of Concern)

(Type of Business)

-

at
(Street Number and Name

(State)

(City)

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:

$

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:

$

(Zip Code)

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

Which is located at:
(Street Number and Name)

(State)

(City)

(Zip Code)
8. The following persons are dependent upon me for support: (Check the box 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

Relationship to Me

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

Date submitted

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

11. I

intend

Relationship

Date submitted

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 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 "Sponsor and Alien Liability" on Page 2 of the instructions for this form, and am aware of my
responsibilities as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.
I certify under penalty of perjury under United States law that I know the contents of this affidavit signed by me and that the statements are
true and correct.
Signature of Sponsor

Date
Form I-134 (Rev. 05/25/11) Y Page 2