Fillable Printable Affidavit of Support Form - New Jersey

Affidavit of Support Form - New Jersey

Department of Homeland Security

U S Cltazenshlp and Immigration Services

OMB No 1615-0014

Form 1-134, Affidavit of Support

(Name)

(Answer all items. Type or print in black ink.)

residing at

(Street Number and Name)

Citazen of (Country)

Presently resades at (Street Number and Name)

(Date-mm/dd/yyyy)

(Middle Name) Gender Age

Relationship to Sponsor

(State) (Country)

Marital Status

(City)

(Caty) (State) (Country)

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

I I was born on in

(Date-mm!dd/yyyy) (Caty) (State) (Country)

If you are not a U S catizen based on your birth an the United States, or a non-citizen U S. national based on your birth m American Samoa (including

Swains Island), answer the following as appropriate

a. If a U S cmzen through naturalization, gave Certificate of Naturalizataon number

b. If a U.S cmzen through parent(s) or marnage, gave Certaficate of Clhzenshmp number

e. IfU.S citizenship was derived by some other method, attach a statement of explanation

d. Ifa Lawful Permanent Resxdent of the United States, give A-Number

e. Ifa lawfully admitted nonmarmgrant, give Form 1-94, Arraval-Departure Record, number

2. I am __ years of age and have resided in the Umted States since

3. Thas affidavit is executed on behalf of the following person"

Name (Family Name) (Farst Name)

(Zap Code ffmU S )

Name of spouse and children accompanying or following to join person"

Spouse Gender Age Child

Gender Age

Child Gender Age Child Gender Age

4. This affidavat is made by me for the purpose of assuring the U S Government that the person(s) named an item (3) wall not become a pubhc

charge in the United States

5. I am walling and able to receive, mamtain, and support the person(s) named In item 3 I am ready and wflhng 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 Umted States, or to guarantee that the above named

person(s) wall maintain his or her nonlmmxgrant status, if admitted temporarily, and wall depart prior to the expiration of his or her authorized stay

m the Umted States.

I understand that"

a. Form 1-134 as an "undertaking" under sectmn 213 of the Immigration and Nationality Act, and I may be sued if the person(s) named m item 3

becomes a pubhc charge after admlssaon to the United States;

b. Form 1-134 may be made available to any Federal, State, or local agency that may reemve an application from the person(s) named in item 3

for Food Stamps, Supplemental Security Income, or Temporary Assistance to Needy Families; and

e. If the person(s) named m item 3 does apply for Food Stamps, Supplemental Security Income, or Temporary Asmstance for Needy Fanuhes,

my own income and assets may be considered an deciding the person's application How long my ancome and assets may be attrabuted to the

person(s) named an item 3 is determined under the statutes and rules governing each specific program

Form 1-134 (Rev 05/25/11) Y

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

(Type of Business)

with

(Name of Concern)

(Street Number and Name (City)

I derwe an annual income of (If self-employed, I have attached a copy of my last income tax return or

report of commercial ratmg 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 m the Umted States $

I have other personal property, the reasonable value ofwhach is' $

I have stocks and bonds wlth the following market value, as indicated on the attached hst, 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 $

(State) (Zlp Code)

Which is located at.

(Street Number and Name) (City) (State) (Zip Code)

8. The followmg persons are dependent upon me for support. (Check the box m the appropriate column to indicate whether the person named is

wholly or partially dependent upon you for support )

Name of Person

[] []

9. I have prevxously submgted affidavit(s) of support for the following person(s) If none, state "None"

Name of Person

Wholly Dependent Partially Dependent Age Relationship to Me

Date submitted

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

Name of Person Relationship Date submitted

11. I [] intend [] do not intend to make specific contrlbutxons to the support of the person(s) named m item 3

(lf you check "intend," indicate the exact nature and duration of the contributions For example, if you intend to furmsh room and board, state

for how long and, if money, state the amount m US dollars and whether ttts to be given m 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 1-134 (Rev 05/25/11) Y Page 2