Pages 1-2,
Part 1. Information
About You (the
Sponsor)
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[Page
1]
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
6.
Date
of Birth (mm/dd/yyyy)
8.
Alien
Registration Number (A-Number) (if any)
7.a.
Town
or City of Birth
7.b.
Country
of Birth
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?
Yes/No
If
you answered "No" to Item
Number 4.,
provide your physical address in Item
Numbers 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
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
[Page
2]
11.c.
I derived my U.S. citizenship by another method. (Provide an
explain 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)
[new]
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[Page 1]
Part
2.
Information
about the
Beneficiary
Complete
Part
2.
regardless of whether you are filing this form on behalf of
yourself as the beneficiary or on behalf of another individual who
is the beneficiary.
1.
Beneficiary’s Current Legal Name
(Do
not provide
a nickname.)
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
2.
Other Names Used
Provide
all
other names the
beneficiary has
ever used, including aliases, maiden name, and nicknames. If you
need extra space to complete this section, use the space provided
in Part
8.
Additional
Information.
Family
Name
(Last Name)
[x2]
Given
Name
(First Name) [x2]
Middle
Name
[x2]
3.
Date of Birth (mm/dd/yyyy)
4.
Gender Male/Female
5.
Alien Registration Number (A-Number)
6.
Place of Birth
City
or Town
State
or Province
Country
7.
Country
of Citizenship or Nationality
8.
Marital Status
Single,
Never Married
Married
Divorced
Widowed
Legally
Separated
Marriage
Annulled
Other
(Explain):
9.
Beneficiary’s
Mailing Address
In
Care
Of Name
Street
Number
and Name
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
Country
10.
Are
the beneficiary’s mailing
address and physical address the same?
Yes/No
If
you answered "No" to Item
Number 10.,
provide the physical address in Item
Number
11.
11.
Beneficiary's
Physical
Address
In
Care Of Name
Street
Number
and Name
(Do
not
provide a PO Box in this space unless it is your ONLY
address.)
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
Country
[delete]
Beneficiary’s
Anticipated Length of Stay
12.
Beneficiary’s
Anticipated Period of Stay in the United States
From
(mm/dd/yyyy)
To
(select one):
[]
(mm/dd/yyyy)
[]
No End Date
[Page
3]
Beneficiary’s
Financial Information
Provide
information about the beneficiary’s income and assets. If
you need additional space to complete any Item
Number in this section, use the
space provided in Part 8.
Additional Information.
Beneficiary’s
Income
13.
Provide all of the information
requested in the table below about the beneficiary, all of the
beneficiary’s dependents, and any other individuals the
beneficiary financially supports (do not include any individuals
named in Part 3.).
Information about assets that are not based on employment should
be added in Item Number 18. and
not in Item Number 13.
Table [4
columns, 8 rows] (See Word Doc for layout)
Individual’s
Full Name (First, Middle, Last)
(do not include any individuals named in Part
3.)
Date of
Birth (mm/dd/yyyy)
Relationship
to the Beneficiary (Type or print
“Self” if you are filing for yourself as the
beneficiary or “Beneficiary” if someone is agreeing to
support you in Part 3.)
Income
contribution to the beneficiary annually (if
none, type or print $0)
Total
Number of Dependents
Total Income
14.
Does any of the beneficiary’s total income (including income
from dependents and other individuals who contribute to the
beneficiary’s income, excluding any individuals named in
Part 3.)
come from an illegal activity or source (such as proceeds from
illegal gambling or illegal drug sales)?
Yes
No
15.
If you answered “Yes” to Item
Number 14., what amount of the
beneficiary’s total income comes from an illegal activity or
source? (Type or print “N/A” if you answered “No”
to Item Number 14.)
$_______
16.
Does any of the beneficiary’s total income come from public
benefits as defined in 8 CFR 212.21(b) or means-tested public
benefits as defined in 8 CFR 213a.1?
Yes
No
17.
If you answered “Yes”
to Item Number 16,
what amount of the beneficiary’s total income comes from
public benefits or means-tested public benefits? (Type or print
“N/A” if you answered “No” to Item
Number 16.) $______
[Page 4]
Beneficiary’s
Assets
18.
In the table below, provide the amounts of assets available to
the beneficiary for the expected period of his or her stay
(excluding assets from any individuals named in Part
3.). Attach evidence showing
that the beneficiary has these assets.
Table [3
columns, 10 rows] (See Word Doc for layout)
Full Name
of Asset Holder
(First,
Middle, Last)
Type of
Asset
Amount
(Cash Value)
(U.S. dollars)
Current Cash
Value (U.S. dollars) $
TOTAL
(U.S. dollars) $
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Page 2,
Part 2. Information
About the Beneficiary
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[Page 2]
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
3.
Gender Male/Female
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
2.
Date of Birth (mm/dd/yyyy)
4.
A-Number (if any)
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
Male/Female
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
Male/Female
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
Male/Female
If
you need additional space to complete this section, use the space
provided in Part
7. Additional Information.
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[Page 4]
Part
3.
Information About the
Individual Agreeing to Financially Support the Beneficiary Named
in Part 2.
[delete]
If
you are not the beneficiary named in Part
2.,
complete Part
3.
If you are the beneficiary named in Part
2.,
type
or print “none” or “N/A” in each field in
Part
3.
before moving to Part
4.
1.
Current
Legal Name
(Do
not provide
a nickname.)
Family
Name
(Last Name)
Given
Name
(First Name)
Middle
Name
2.
Other
Names Used
Provide
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
8. Additional Information.
Family
Name (Last Name) [x2]
Given
Name (First Name) [x2]
Middle
Name [x2]
[delete]
3.
Current
Mailing Address
In
Care Of Name
Street
Number
and Name
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
Country
4.
Is your current mailing address the same as your current physical
address?
Yes/No
If
you answered "No" to Item
Number 4.,
provide your current physical address in Item
Number 5.
5.
Physical
Address
In
Care Of Name
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Other
Information
6.
Date
of Birth (mm/dd/yyyy)
7.
Place
of Birth
City
or Town
State
or Province
Country
8.
Alien
Registration Number (A-Number)
9.
USCIS Online Account Number
Immigration
Status
10.
What is your current immigration status? Provide documentation as
provided in the instructions.
U.S.
Citizen
U.S.
National
Lawful
Permanent Resident A-Number
Nonimmigrant
Form I-94 Arrival/Departure Record Number
Other
(Explain): ______
Employment
Information
11.
Employment Status
[ ] Employed
(full-time, part-time, seasonal, self-employed)
[ ] Unemployed
or Not Employed
[ ] Retired
[ ] Other
(Explain):
If
you indicated that you are employed in Item
Number 11.,
provide the information requested in Item
Numbers 12. - 13.
If
you selected a different option in Item
Number 11.,
type or print “N/A” in Item
Numbers 12. - 13.
12.A.
I am currently employed as a/an
Name
of Employer
B.
I am currently self-employed as a/an
13.
Current
Employer’s Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Financial
Information
Provide
information about your income and assets. If you need additional
space to complete any Item
Number
in this section, use the space provided in Part
8. Additional Information.
Income
14.
Provide all of the information requested in the table below about
yourself, all of your dependents, and any other individuals you
financially support (do not include any individuals named in Part
2.). Information about assets
that are not based on employment should be added in Item
Number 19. and not in Item
Number 14.
Table [4
columns, 8 rows] (See Word Doc for layout)
Full Name
(First, Middle, Last) (do
not include any individuals named in Part
2.)
Date of
Birth (mm/dd/yyyy)
Relationship
to the Individual Agreeing to Financially Support (Type
or print “Self” for Individual Agreeing to Financially
Support the Beneficiary)
Income
Contribution to the Beneficiary Annually (if
none, type or print $0)
Total
Number of Dependents
Total Income
[Page 15]
15.
Does any of the income listed above come from an illegal activity
or source (such as proceeds from illegal gambling or illegal drug
sales)?
Yes
No
16.
If you answered “Yes” to Item
Number 15., what amount of income
comes from an illegal activity? (Type or print “N/A”
if you answered “No” to Item
Number 15.) $______
17.
Does any of the income listed above come from public benefits as
defined in 8 CFR 212.21(b) or means-tested public benefits as
defined in 8 CFR 213a.1?
Yes
No
18. If
you answered “Yes” to Item
Number 17., what amount of income
is from public benefits or means-tested public benefits? (Type
or print “N/A” if you answered “No” to
Item Number 17.)
$______
Assets
19.
Fill out the table below regarding the assets available to you
(do
not include any assets from any individuals named in Part
2.).
Attach evidence showing you have these assets.
Table [3
columns, 10 rows] (See Word Doc for layout)
Full Name
of Asset Holder
(you or your
household member)
Type of
Asset
Amount
(Cash Value)
(U.S. dollars)
Current Cash
Value (U.S. dollars) $
TOTAL
(U.S. dollars) $
Financial
Responsibility for Other Beneficiaries
20.
Have you previously submitted a Form I-134 on behalf of a person
other than the beneficiary listed on this Form I-134?
Yes
No
If
you answered “Yes” to Item
Number 20.,
provide the information requested in Item
Numbers 21. - 22.
(Type or print “N/A” in Item
Numbers 21. - 22.
if you answered “No” to Item
Number 20.)
If you need additional space to complete this section, use the
space provided in Part
8. Additional Information.
21.
Person
1
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
A-Number
Date
Submitted (mm/dd/yyyy)
22.
Person
2
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
A-Number
Date
Submitted (mm/dd/yyyy)
Intent
to Provide Specific Contributions to the Beneficiary
23.
I [] intend [] do not intend to make specific contributions to the
support of the beneficiary named in Part
2.
Explain
the contribution. For example, if you intend to furnish room and
board, state for how long. If you intend to provide 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. If you need additional
space, use Part
8. Additional Information.
[delete]
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Pages 3-4,
Part 3. Other
Information About the Sponsor
|
[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.
Apt./Ste./Flr.
9.c.
City or Town
9.d.
State
9.e.
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)
[Page
4]
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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[delete]
|
New
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[Page 8]
Part
4. Statement, Contact Information, Certification, and Signature
of the Beneficiary (if filing Form I-134 on his or her own behalf)
If
you are the beneficiary and are filing Form I-134 on your own
behalf, complete and sign Part
4. If
you are not the beneficiary who is filing Form I-134 on your own
behalf, type or print “N/A” in Item
Numbers 1. - 6.
NOTE:
Read the Penalties
section of the Form I-134 Instructions before completing this
section.
Beneficiary’s
Statement
NOTE:
Select the box for either Item
A.
or B.
in Item
Number 1.
If applicable, select the box for Item
Number 2.
1.
I,
as the beneficiary, certify the following:
A.
I can read and understand English, and I have read and understand
every question and instruction on this declaration and my answer
to every question.
B.
The interpreter named in Part
6.
read to me every question and instruction on this declaration 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
7.,
[Fillable Field], prepared this declaration for me based only upon
information I provided or authorized.
Beneficiary's
Contact Information
3.
Beneficiary’s Daytime Telephone Number
4.
Beneficiary’s Mobile Telephone Number (if any)
5.
Beneficiary’s Email Address (if any)
Beneficiary’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 and all 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
declaration, 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 law.
[Page
9]
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
declaration;
2)
I understood all of the information contained in, and submitted
with, my declaration; 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 declaration, I understand all of the
information contained in, and submitted with, my declaration, and
that all of this information is complete, true, and correct.
That
this declaration is made by me to assure the U.S. Government that
I will be able to financially support myself while in the United
States.
That
I am willing and able to pay for necessary expenses for the
duration of my temporary stay in the United States.
Beneficiary’s
Signature
6.
Beneficiary’s Signature
Date
of Signature (mm/dd/yyyy)
|
Pages 5-6,
Part 4. Sponsor’s
Statement, Contact Information, Certification, and Signature
|
[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 Field], 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)
[Page
6]
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 9]
Part
5.
Statement, Contact
Information, Certification, and Signature
of the Individual Agreeing to Financially Support the Beneficiary
If
you are filing Form I-134 on behalf of someone else (the
beneficiary listed in Part
2.),
complete and sign Part
5.
If
you are the beneficiary and are filing Form I-134 on your own
behalf, type or print “N/A” in Item
Numbers 1. - 6.
NOTE:
Read the Penalties
section of the Form I-134 Instructions before completing this
section.
Statement
of Individual Agreeing to Financially Support the Beneficiary
NOTE:
Select the box for either Item
A. or
B.
in Item
Number 1.
If applicable, select the box for Item
Number 2.
1. I,
as the individual agreeing to financially support the beneficiary,
certify the following:
A.
I
can read and understand English, and I have read and understand
every question and instruction on this declaration
and
my answer to every question.
B.
The
interpreter named in Part
6.
read to me every question and instruction on this declaration
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
7.,
[Fillable Field], prepared this declaration
for
me based only upon information I provided or authorized.
Contact
Information for Individual Agreeing to Financially Support the
Beneficiary
3.
Daytime
Telephone
Number
4.
Mobile
Telephone
Number (if any)
5.
Email
Address
(if any)
[Page
10]
Certification
of Individual Agreeing to Financially Support the Beneficiary
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 and
all 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
declaration,
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 law.
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
declaration;
2)
I understood all of the information contained in, and submitted
with, my declaration;
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 declaration,
I understand all of the information contained in, and submitted
with, my declaration,
and that all of this information is complete, true, and correct.
That
this declaration
is
made by me to assure the U.S. Government that the person named in
Part
2.
will
be financially supported while
in the United States.
That
I am willing and able to receive, maintain, and support the person
named in Part
2. to
better ensure
that such persons will have
sufficient financial resources or financial support to pay for
necessary expenses for the period of his or
her temporary
stay
in the United States.
[delete]
I
acknowledge that I have read this
section,
and I am
aware of my responsibilities as an
individual agreeing to financially support the beneficiary.
Signature
of Individual Agreeing to Financially Support the Beneficiary
6.
Signature
Date
of
Signature (mm/dd/yyyy)
NOTE
TO ALL INDIVIDUALS
AGREEING TO FINANCIALLY SUPPORT THE BENEFICIARY:
If you do not completely fill out this declaration
or
if
you fail
to submit required documents listed in the Instructions, USCIS or
the Department of State may deny or
not consider
your declaration.
|
Page 6,
Part 5.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 6]
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 10]
Part
6.
Interpreter's Contact Information, Certification, and Signature
Provide
the following information about the interpreter.
Interpreter's
Full Name
1.
Interpreter's Family
Name (Last Name)
Interpreter's
Given
Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
[Page
11]
Interpreter's
Mailing Address
3.
Street
Number and Name
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
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 specified
in
Part
4. or
in
Part 5.,
Item
B.
in Item
Number 1.,
and I have read to this individual
agreeing to financially support the beneficiary
in the identified language every question and instruction on this
declaration
and
his or her answer to every question. The individual
agreeing to financially support the beneficiary informed
me that he or she understands every instruction, question, and
answer on the declaration,
including the Certification
of
the Individual Agreeing to Financially Support the Beneficiary,
and has verified the accuracy of every answer.
Interpreter's
Signature
7.
Interpreter's
Signature
Date
of
Signature (mm/dd/yyyy)
|
Pages 6-7,
Part 6. Contact
Information, Statement, Declaration, and Signature of the Person
Preparing this Affidavit, if Other Than the Sponsor
|
[Page 6]
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
[Page
7]
Preparer's
Contact Information
4.
Preparer's
Daytime Telephone Number
5.
Preparer's
Fax Number
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
application.
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 11]
Part
7.
Contact Information,
Declaration,
and Signature of the Person Preparing this Declaration,
if Other Than the Individual
Agreeing to Financially Support the Beneficiary
Provide
the following information about the preparer.
Preparer's
Full Name
1.
Preparer's
Family Name (Last Name)
Preparer's
Given Name (First Name)
2.
Preparer's
Business or Organization Name (if any)
[Page
12]
Preparer's
Mailing Address
3.
Street
Number and Name
Apt./Ste./Flr.
Number
City
or
Town
State
ZIP
Code
Province
Postal
Code
Country
Preparer's
Contact Information
4.
Preparer's
Daytime Telephone Number
5.
Preparer's
Mobile
Telephone Number
6.
Preparer's
Email Address (if any)
Preparer's
Statement
7.A.
I
am not an attorney or accredited representative but have prepared
this declaration
on
behalf of the
individual agreeing to financially support the beneficiary (which
is the beneficiary if filing on behalf of him or herself) and
with that
individual’s
consent.
B.
I
am an attorney or accredited representative and my representation
of the
individual agreeing to financially support the beneficiary (which
is the beneficiary if filing on behalf of him or herself) in
this case extends/does
not extend
beyond
the preparation of this declaration.
NOTE:
If you are an attorney or accredited representative,
you
may
need
to
submit a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this application.
Preparer's
Certification
By
my signature, I certify, under penalty of perjury, that I prepared
this declaration
at
the request of the individual
agreeing to financially support the beneficiary (which is the
beneficiary if filing on behalf of him or herself).
The individual
agreeing to financially support the beneficiary
(which
is the beneficiary if filing on behalf of him or herself) then
reviewed this completed declaration
and
informed me that he or she understands all of the information
contained in, and submitted with, his or her declaration,
including the Certification
of
the Individual Agreeing to Financially Support the Beneficiary,
and that all of this information is complete, true, and correct.
I completed this declaration
based only on information that the individual
agreeing to financially support the beneficiary provided
to me or authorized me to obtain or use.
Preparer's
Signature
8.
Preparer's
Signature
Date
of
Signature (mm/dd/yyyy)
|