Page 1,
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(Answer
all items. Type or print in black ink.)
I,
__________(Name),
Certify
under penalty of perjury under U.S. law, that:
residing
at
Street
Number and Name
City
State
Zip
Code if in U.S.,
Country
1.
I was born on __________(Date (mm/dd/yyyy)
in ____________(City, State, Country).
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:
If a U.S.citizen through
naturalization, give Certificate of Naturalization number_______
If a U.S. citizen through
parent(s) or marriage, give Certificate of Citizenship
number_________
If U.S. citizenship was
derived by some other method, attach
a statement of explanation.
If a Lawful Permanent
Resident of the United States, give A-Number____
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)
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[Page
1]
START
HERE - Type or print in black ink.
Part
1. Information About You (the
Sponsor)
Your
Full Name
1.a.
Family Name (Last Name)
1.b.
Given Name (First Name)
1.c.
Middle Name
Other
Names Used
List
all other names you have ever used, including aliases, maiden
name, and nicknames. If you need extra space to complete this
section, use the space provided in Part
7. Additional Information.
2.a.
Family Name (Last Name)
2.b.
Given Name (First Name)
2.c.
Middle Name
Sponsor’s
Mailing Address
3.a.
In Care Of Name
3.b.
Street
Number and Name
3.c.
Apt. Ste. Flr.
3.d.
City or Town
3.e.
State
3.f.
ZIP
Code
3.g.
Province
3.h.
Postal Code
3.i.
Country
4.
Are
your mailing address and physical address the same?
Y/N
If
you answered “No” to Item
Number 4.,
provide your physical address in Item
Number 5.a. - 5.h.
Sponsor’s
Physical Address
5.a.
Street Number and Name
5.b.
Apt. Ste. Flr.
5.c.
City or Town
5.d.
State
5.e.
ZIP Code
5.f.
Province
5.g.
Postal Code
5.h.
Country
Other
Information
6.
Date of Birth (mm/dd/yyyy)
7.a.
Town or City of Birth
7b.
Country of Birth
8.
Alien Registration Number (A-Number) (if any)
9.
U.S. Social Security Number (if any)
10.
USCIS Online Account Number (if any)
Citizenship
or Residency or Status
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:
11.a.
[ ] I am a U.S. citizen
through naturalization. My
Certificate of Naturalization number is _______
11.b.
[ ] I am a U.S. citizen
through parent(s) or marriage. My Certificate of Citizenship
number is _________
11.c.
I derived my U.S. citizenship by another method.. (Provide an
explanation in Part
7. Additional Information.)
11.d.
[ ] I am a lawful permanent resident of the United States. My
A-Number is _____
11.e.
[ ] I am a lawfully admitted nonimmigrant. My Form I-94,
Arrival-Departure Record Number is _______
12.
I am __ years of age and have resided in the United States since
(Date)(mm/dd/yyyy)____________.
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Page 1,
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3.This affidavit is executed
on behalf of the following person:
Name (Family Name)
(First Name)
(Middle Name)
Age
Gender
Citizen of (Country)
Marital Status
Relationship to Sponsor
Presently resides at (Street
Number and Name)
City
State
Country
Name of spouse and children
accompanying or following to join person:
Spouse
Age
Gender
Child
Age
Gender
Child
Age
Gender
Child
Gender
Age
Child
Gender
Age
Child
Gender
Age
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[Page
1]
Part
2. Information About the Beneficiary
This
affidavit is executed on behalf of the following person:
1.a.
Family Name (Last Name)
1.b.
Given Name (First Name)
1.c.
Middle Name
2.
Date
of Birth (mm/dd/yyyy)
3.
Gender
4.
A-Number (if any)
5.
Country of Citizenship or Nationality
6.
Marital Status
Single
or Single, Never Married
Married
Divorced
Widowed
Legally
Separated
Marriage
Annulled
Other
7.
Relationship to Sponsor
Beneficiary’s
Physical Address
8.a.
Street Number and Name
8.b.
Apt. Ste. Flr.
8.c.
City or Town
8.d.
State
8.e.
ZIP Code
8.f.
Province
8.g.
Postal Code
8.h.
Country
Beneficiary’s
Spouse (accompanying or following to join beneficiary)
9.a.
Family
Name (Last Name)
9.b.
Given
Name (First Name)
9.c.
Middle Name
10.
Date
of Birth (mm/dd/yyyy)
11.
Gender
Beneficiary’s
Children
Child
1
12.a.
Family Name (Last Name)
12.b.
Given Name (First Name)
12.c.
Middle Name
13.
Date
of Birth (mm/dd/yyyy)
14.
Gender
Child
2
15.a.
Family Name (Last Name)
15.b.
Given Name (First Name)
15.c.
Middle Name
16.
Date
of Birth (mm/dd/yyyy)
17.
Gender
[deleted]
[deleted]
[deleted]
If
you need additional space to complete this section, use the space
provided in Part
7. Additional Information.
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Page 2,
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7.
I am employed as or engaged in the business of ____(Type of
Business) with ___(Name of Concern) at
Street
Number and Name
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
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: $_________
With
mortgage(s) or
other encumbrance(s) thereon amounting to: $_________
Which
is located at:
Street
Number and Name
City
State
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
Relationship
to Me
Age
Wholly
Dependent
Partially
Dependent
Name
of Person
Relationship
to Me
Age
Wholly
Dependent
Partially
Dependent
Name
of Person
Relationship
to Me
Age
Wholly
Dependent
Partially
Dependent
9.
I have previously submitted affidavit(s) of support for the
following person(s). If none, state “None”.
Name
of Person
Date
Submitted
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
Date
Submitted
Name
of Person
Relationship
Date
Submitted
Name
of Person
Relationship
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 whether
it is to be given in a lump sum, weekly or monthly, and for how
long.
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[Page 3]
Part
3. Other Information About
the Sponsor
Employment
Information
I
am currently:
1.a.
__ Employed
as a/an ___________
1.a.1.
Name of Employer (if applicable)
1.b.
Self
employed as a/an___________
Current
Employer
Address (if
employed)
2.a.
Street Number and Name
2.b.
Apt. Ste. Flr.
2.c.
City or Town
2.d.
State
2.e.
ZIP Code
2.f.
Province
2.g.
Postal Code
2.h.
Country
Income
and Asset Information
3.
My annual income is $_________
(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.)
4.
Balance
of all my savings and checking accounts in United States-based
financial institutions $_________
5.
Value of my other personal property $__________
6.
Market value of my stocks and bonds
$____________
.
I
have listed my stocks and bonds in Part
7. Additional Information (or
attached a list of them), which I certify to
be true and correct to the best of my knowledge and belief.
7.
a. I have life
insurance in the sum of $_________
7.b.
With a cash
surrender value of $________
Real
Estate Information
8.a.
I
own real estate valued at $___
8.b.
I have mortgages or other debts amounting to $_______
My
real estate is
located at:
9.a.
Street Number and
Name
9.b.
City
9.c.
State
9.d.
ZIP Code
Dependents’
Information
The
following persons are dependent upon me for support. If
you need extra space to complete this section, use the space
provided in Part
7. Additional Information.
10.a.
Family Name (Last Name)
10.b.
Given Name (First Name)
10.c.
Middle Name
11.
Relationship to
Me:
12.
Date of Birth (mm/dd/yyyy)
13.
This
person is:
[]
Wholly Dependent On
Me For Support
[]
Partially Dependent On
Me For Support
14.a.
Family Name (Last Name)
14.b.
Given Name (First Name)
14.c.
Middle Name
15.
Relationship to
Me:
16.
Date of Birth (mm/dd/yyyy)
17.
This person is:
[]
Wholly Dependent On
Me For Support
[]
Partially Dependent On
Me For Support
18.a.
Family Name (Last Name)
18.b.
Given Name (First Name)
18.c.
Middle Name
19.
Relationship to
Me:
20.
Date of Birth (mm/dd/yyyy)
21.
This person is:
[]
Wholly Dependent On
Me For Support
[]
Partially Dependent On
Me For Support
I
have previously submitted affidavit(s) of support for the
following person(s). (If
none, write
“None” in the space for name below.)
22.a.
Family Name (Last Name)
22.b.
Given Name (First Name)
22.c.
Middle Name
23.
Date Submitted (mm/dd/yyyy)
24.a.
Family Name (Last Name)
24.b.
Given Name (First Name)
24.c.
Middle Name
25.
Date Submitted (mm/dd/yyyy)
I
have submitted a visa petition(s) to U.S. Citizenship and
Immigration Services on behalf of the following persons. (If
none, write
“None” in the space for name below.)
26.a.
Family Name (Last Name)
26.b.
Given Name (First Name)
26.c.
Middle Name
27.
Relationship to Me:
28.
Date of Birth (mm/dd/yyyy)
29.
Date of Filing (mm/dd/yyyy)
30.a.
Family Name (Last Name)
30.b.
Given Name (First Name)
30.c.
Middle Name
31.
Relationship to Me:
32.
Date of Birth (mm/dd/yyyy)
33.
Date of Filing (mm/dd/yyyy)
34.a.
Family Name (Last Name)
34.b.
Given Name (First Name)
34.c.
Middle Name
35.
Relationship to Me:
36.
Date of Birth (mm/dd/yyyy)
37.
Date of Filing (mm/dd/yyyy)
38.
I __ intend
__do not intend to make specific contributions to the support of
the person(s) named in Part
2.
(If you select
"intend,"
indicate the exact nature and duration of the contributions you
intend to make in
Part
7. Additional Information.
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.
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Page 2,
Oath or Affirmation of
Sponsor
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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.
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:
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;
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
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.
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.
Signature
of Sponsor
Date
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[Page
5]
Part
4. Sponsor’s
Statement,
Contact Information, Certification, and Signature
NOTE:
Read the Penalties section of the Form I-134 Instructions before
completing this part.
Sponsor’s
Statement
NOTE:
Select the box for either Item
Number 1.a. or
1.b.
If applicable, select the box for Item
Number 2.
1.a.
[]
I
can read and understand English, and I have read and understand
every question and instruction on this affidavit,
and my answer to every question.
1.b.
[]
The interpreter named in Part
5.
read to me every
question and instruction on this affidavit,
and my answer to every question, in [Fillable Field], a language
in which I am fluent and I understood everything.
2.
[]
At
my request, the preparer named in Part
6.,
[Fillable Filed], prepared this
affidavit
for
me
based only upon information I provided or authorized.
Sponsor’s
Contact Information
3.
Sponsor’s Daytime
Telephone Number
4.
Sponsor’s Mobile
Telephone Number (if any)
5.
Sponsor’s Email
Address (if any)
Sponsor’s
Certification
Copies
of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS or
the Department of State may
require that I submit original documents to USCIS or
the Department of State at
a later date. Furthermore, I authorize the release of any
information from any of my records that USCIS or
the Department of State may
need to determine my eligibility for the immigration benefit I
seek.
I
further authorize release of information contained in this
affidavit,
in supporting documents, and in my USCIS or
the Department of State records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I
understand that USCIS may require me to appear for an appointment
to take my biometrics (fingerprints, photograph, and/or signature)
and, at that time, if I am required to provide biometrics, I will
be required to sign an oath reaffirming that:
1)
I reviewed and provided or authorized all of the information in my
affidavit;
2)
I understood all of the information contained in, and submitted
with, my affidavit; and
3)
All of this information was complete, true, and correct at the
time of filing.
I
certify, under penalty of perjury, that I provided or authorized
all of the information in my affidavit,
I understand all of the information contained in, and submitted
with, my affidavit, and that all of this information is
complete, true, and correct
That
this affidavit is made by me to assure the U.S. Government that
the person named in Part
2. will not
become a public charge in the United States.
That
I
am willing and able to receive, maintain, and support the person
named in Part
2. I
am ready and willing to deposit a bond, if necessary, to guarantee
that such persons will not become a public charge during his or
her stay in the United States, or to guarantee that the above
named persons 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.
That I
understand that Form I-134 is an “undertaking” under
section 213 of
the Immigration and Nationality Act, and I may be sued if the
persons named in Part
2. become
a public charge after admission to the United States.
That I
understand that
Form
I-134 may be made available to any Federal, State, or local agency
that may receive an application from the persons named in Part
2. for
Food Stamps, Supplemental Security Income, or Temporary Assistance
to Needy Families.
That I
understand that
if
the person named in Part
2.
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 persons named in Part
2. is
determined under the statutes and rules governing each specific
program.
I acknowledge that I have read
the section entitled Sponsor
and Beneficiary Liability
in the
Instructions for this affidavit,
and am aware of my responsibilities as a sponsor under the Social
Security Act, as amended, and the Food Stamp Act, as amended.
Sponsor’s
Signature
6.a.
Sponsor’s Signature
6.b.
Date of Signature (mm/dd/yyyy)
NOTE
TO ALL SPONSORS:
If you do not completely fill out this affidavit
or
fail to submit required documents listed in the Instructions,
USCIS or
the Department of State may
deny your affidavit.
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[Page
6]
[New]
Part
5. Interpreter’s Contact Information,
Certification,
and Signature
Provide
the following information about
the
interpreter.
Interpreter’s
Full Name
1.a.
Interpreter’s Family Name (Last Name)
1.b.
Interpreter’s Given Name (First Name)
2.
Interpreter’s Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Interpreter’s
Contact Information
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Mobile Telephone Number (if any)
6.
Interpreter’s Email Address (if any)
Interpreter’s
Certification
I
certify, under penalty of perjury, that:
I
am fluent in English and [Fillable
Field],
which
is the same language provided in Part
4.,
Item
Number 1.b.,
and I have
read to this sponsor
in the identified language every
question and instruction on this affidavit
and his or her answer
to every question.
The sponsor informed me
that he or she understands every instruction,
question, and answer on
the affidavit,
including the Sponsor’s
Certification,
and has verified
the accuracy of every answer.
Interpreter’s
Signature
7.a.
Interpreter’s Signature
7.b.
Date of Signature (mm/dd/yyyy)
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[Page
6]
[New]
Part
6. Contact Information, Statement, Declaration,
and Signature of the Person Preparing this Affidavit,
if Other
Than the Sponsor
Provide
the following information about the preparer.
Preparer’s
Full Name
1.a.
Preparer’s Family Name (Last Name)
1.b.
Preparer’s Given Name (First Name)
2.
Preparer’s Business or Organization Name (if any)
Preparer’s
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Preparer’s
Contact Information
4.
Preparer’s Daytime Telephone Number
5.
Preparer’s Mobile Telephone Number (if any)
6.
Preparer’s Email Address (if any)
Preparer’s
Statement
7.a.
[] I
am not an attorney or accredited representative but have prepared
this
affidavit on
behalf of the sponsor
and
with the sponsor’s
consent.
7.b.
[] I
am an attorney or accredited representative and my representation
of the sponsor
in
this case
[] extends [] does not extend
beyond
the preparation of this affidavit.
NOTE:
If you are an attorney or accredited representative whose
representation extends beyond preparation of this affidavit,
you may
be obliged to submit
a completed Form G-28, Notice of Entry of Appearance as Attorney
or Accredited Representative, with this
with
this affidavit.
Preparer’s
Certification
By
my signature, I certify,
under penalty of
perjury, that I prepared this affidavit
at the
request of
the sponsor. The sponsor then reviewed this completed affidavit
and
informed me that he or she understands all of the information
contained in, and submitted with, his or her affidavit, including
the Sponsor’s
Certification,
and that all of this information is complete, true, and correct.
I completed this affidavit
based
only on information that the sponsor provided to me or authorized
me to obtain or use.
Preparer’s
Signature
8.a.
Preparer’s Signature
8.b.
Date of Signature (mm/dd/yyyy)
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