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I-134-FRM-TOC-EXT SL-WIP-02232016.docx

Affidavit of Support

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OMB: 1615-0014

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TABLE OF CHANGES – FORM

Form I-134, Affidavit of Support

OMB Number: 1615-0014

2/23/2016



Reason for Revision: Extension with Standard Language updates




Current Page Number and Section

Current Text

Proposed Text

Page 1,




(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:


  1. If a U.S.citizen through naturalization, give Certificate of Naturalization number_______



  1. If a U.S. citizen through parent(s) or marriage, give Certificate of Citizenship number_________


  1. If U.S. citizenship was derived by some other method, attach a statement of explanation.



  1. If a Lawful Permanent Resident of the United States, give A-Number____


  1. 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)

[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)____________.















Page 1,






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


[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.


Page 2,







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.


[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.


Page 2,

Oath or Affirmation of Sponsor



















































































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:


  1. 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;


  1. 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


  1. 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

[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.




[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)













[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)




[Page 8]

[New]


Part 7. Additional Information

If you need extra space to provide any additional information within this affidavit, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this affidavit or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; type or print the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.


Your Full Name


1.a. Family Name (Last Name) [Auto-populated field]

1.b. Given Name (First Name) [Auto-populated field]

1.c. Middle Name [Auto-populated field]


2. A-Number (if any) [Auto-populated field]


3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d. ____________________



4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d. ____________________


5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d. ___________________


6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d. ____________________


7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d. ____________________





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