Fillable Printable Affidavit of Support Form - North Carolina

Affidavit of Support Form - North Carolina

I-134, Affidavit of Support

Instructions

An alien applying for SSI must make available to the Social

Security Administration documentation concerning his / her

income and resources and those of the sponsor, including

information that was provided in support of the corresponding

application.

A separate affidavit must be submitted for each person. As

the sponsor, you must sign the affidavit in your full, true

and correct name and affirm or make it under oath.

As the sponsor, you must show you have sufficient income

and/or financial resources to assure that the alien you are

sponsoring will not become a public charge while in the

United States.

Evidence should consist of copies of any or all of the

following documentation listed below that are applicable to

your situation.

Failure to provide evidence of sufficient income and/or

financial resources may result in the denial of the alien's

application for a visa or his or her removal from the United

States.

The sponsor must submit in duplicate evidence of income

and resources, as appropriate:

A. Statement from an officer of the bank or other financial

institutions where you have deposits, identifying the

following details regarding your account:

1. Date account opened;

B. Statement of your employer on business stationery,

revealing:

1. Date and nature of employment;

C. If self-employed:

2. Report of commercial rating concern.

D. List containing serial numbers and denominations of

bonds and name of record owner(s).

I. Execution of Affidavit.

II. Supporting Evidence.

Effective October 1, 1981, amendments to section 415 of the

Social Security Act established similar requirements for

determining the eligibility of aliens who apply for the first

time for Aid to Families with Dependent Children (AFDC),

currently administered under Temporary Assistance for Needy

Families (TANF). Effective December 22, 1981, amendents to

the Food Stamp Act of 1977 affect the eligibility of alien

participation in the Food Stamp Program.

These amendments require that the income and resources of

any person who, as the sponsor of an alien's entry into the

United States, executes an affidavit of support or similar

agreement on behalf of the alien, and the income and

resources of the sponsor's spouse (if living with the sponsor)

shall be deemed to be the income and resources of the alien

under formulas for determining eligibility for SSI, TANF and

Food Stamp benefits during the three years following the

alien's entry into the United States.

Form I-134 (Rev. 02/28/07)Y

OMB No. 1615-0014; Exp. 04-30-07

Effective October 1, 1980, amendments to section 1614(f) of

the Social Security Act and Part A of Title XVI of the Social

Security Act establish certain requirements for determining

the eligibility of aliens who apply for the first time for

Supplemental Security Income (SSI) benefits.

III. Sponsor and Alien Liability.

If you are in the United States, the affidavit may be

sworn to or affirmed before an officer of U.S. Citizenship

and Immigration Services (USCIS) without the payment of

fee, or before a notary public or other officers authorized

to administer oaths for general purposes, in which case the

official seal or certificate of authority to administer oaths

must be affixed.

If you are outside the United States, the affidavit

must be sworn to or notice affirmed before a U.S.

consular or immigration officer.

Documentation on Income and Resources.

Department of Homeland Security

U.S. Citizenship and Immigration Services

How you submit the form depends on whether the alien you

are sponsoring is in or outside the United States and what type

of application is being submitted. See the instructions

provided with the corresponding application for detailed

information on how to submit this affidavit of support form.

2. Total amount deposited for the past year;

3. Present balance.

2. Salary paid;

3. Whether the position is temporary or permanent.

1. Copy of last income tax return filed; or

The information may also as a matter of routine use be

disclosed to other federal, state, local and foreign law

enforcement and regulatory agencies, including the

Department of Health and Human Services, Department of

Agriculture, Department of State, Department of Defense and

any component thereof ( if the deponent has served or is

serving in the armed forces of the United States), Central

Intelligence Agency, and individuals and organizations during

the course of any investigation to elicit further information

required to carry out USCIS functions.

However, failure to provide the information may result in the

denial of the alien's application.

Form I-134 (Rev. 02/28/07)Y Page 2

IV. Information and USCIS Forms.

For information on immigration laws, regulations and

procedures or to order USCIS forms, call our National

Customer Service Center at 1-800-375-5283 or visit our

website at www.uscis.gov.

VII. Paperwork Reduction Act Notice.

The information will be used principally by USCIS, or by any

consular officer to whom it may be furnished, to support an

alien's application for benefits under the Immigration and

Nationality Act and specifically the assertion that he or she

has adequate means of financial support and will not become a

public charge. Submission of the information is voluntary.

These provisions do not apply to SSI, TANF or Food

Stamp eligibility of aliens admitted as refugees, granted

asylum or Cuban/ Haitian entrants as defined in section

501(e) of P.L. 96-422, and to dependent children of the

sponsor or sponsor's spouse.

As an alternative to waiting in line for assistance at your local

USCIS office, you can now schedule an appointment through

our internet-based system, InfoPass. To access the system,

visit our website at www.uscis.gov. Use the InfoPass

appointment scheduler and follow the screen prompts to set up

your appointment. InfoPass generates an electronic

appointment notice that appears on the screen. Print the notice

and take it with you to your appointment. The notice gives the

time and date of your appointment, along with the address of

the USCIS office.

V. Use InfoPass for Appointments.

You are not required to respond to this form unless it displays

a currently valid OMB control number.

Joint and Several Liability Issues.

Sections 1621(e) of the Social Security Act and

subsection 5(i) of the Food Stamp Act also provide that an

alien and his or her sponsor shall be jointly and severally

liable to repay any SSI, TANF or Food Stamp benefits that are

incorrectly paid because of mis-information provided by a

sponsor or because of a sponsor's failure to provide

information, except where the sponsor was without fault or

where good cause existed.

Incorrect payments that are not repaid will be withheld from

any subsequent payments for which the alien or sponsor are

otherwise eligible under the Social Security Act or Food

Stamp Act.

The Secretary of Health and Human Services and the

Secretary of Agriculture are authorized to obtain copies of

any such documentation submitted to USCIS or the U.S.

Department of State and to release such documentation to a

State public assistance agency.

An alien applying for TANF or Food Stamps must make

similar information available to the State public assistance

agency.

Authority for the collection of the information requested on

this form is contained in 8 U.S.C. 1182(a)(4),1183(a),1184(a)

and 1258.

We ask for the information on this form and associated

evidence to determine if you have established eligibility for

the immigration benefit you are seeking. We may provide this

information to other government agencies. Failure to provide

this information and any requested evidence may delay a final

decision or result in denial of your request.

VI. Privacy Act Notice.

We try to create forms and instructions that are accurate, can

be easily understood and impose the least possible burden on

you to provide us with information. Often this is difficult

because some immigration laws are very complex.

The estimated average time to complete and file this notice is

15 minutes.

If you have comments regarding the accuracy of this estimate,

or suggestions for making this form simpler, you may write to:

U.S. Citizenship and Immigration Services, Regulatory

Management Division, 111 Massachusetts Avenue, N.W., 3rd

Floor, Suite 3008, Washington, DC 20529. Do not mail your

completed affidavit of support to this address.

OMB No. 1615-0014; Exp. 04-30-07

I-134, Affidavit of Support

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

1. I was born on

(City)

If you are not a native born U.S. citizen, answer the following as appropriate:

a. If a U.S.citizen through naturalization, give certificate of naturalization number

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

d. If a lawfully admitted permanent resident of the United States, give "A" number

2. I am

years of age and have resided in the United States since (date)

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

Gender

Age

(Middle Name)

Citizen of (Country) Relationship to Sponsor

Marital Status

Presently resides at (Street and Number) (Country)(City) (State)

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

Child

Gender Age

Child Gender Age

Spouse Age

Child

Child Gender Age

with

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

(Name of Concern)

(Type of Business)

(Zip Code)

(State)

(City)(Street and Number)

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:

Department of Homeland Security

U.S. Citizenship and Immigration Services

Being duly sworn depose and say:

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.

I am willing and able to receive, maintain and support the person(s) named in item 3. That 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.

I understand this affidavit will be binding upon me for a period of three (3) years after entry of the person(s) named in

item (3) and that the information and documentation provided by me may be made available to the Secretary of Health and Human

Services and the Secretary of Agriculture, who may make it available to a public assistance agency.

Gender

Age

(Date-mm/dd/yyyy)

Form I-134 (Rev. 02/28/07) Y

(Country)

I have other personal property, the reasonable value of which is:

b. If a U.S. citizen through parent(s) or marriage, give citizenship certificate number

Name (Family Name) (First Name)

residing at

(Street and Number)

(Name)

(Zip Code if in U.S.) (Country)(State)

(City)

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:

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

Which is located at:

(Zip Code)

(City) (State)(Street and Number)

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

10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services (USCIS) on behalf of the

following person(s). If none, state none.

Date submitted

Relationship

Name

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 state 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 Part lll of the Instructions, Sponsor and Alien Liability, 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

day ofSubscribed and sworn to (affirmed) before me this

at . My commission expires on

Title

If the affidavit is prepared by someone other than the sponsor, please complete the following: I declare that this document

was prepared by me at the request of the sponsor and is based on all information of which I have knowledge.

(Date)(Signature) (Address)

I have life insurance in the sum of:

I own real estate valued at:

The following persons are dependent upon me for support: (Place an "x" in the appropriate column to indicate

whether the person named is wholly or partially dependent upon you for support.)

Date submitted

Form I-134 (Rev. 02/28/07)YPage 2

I swear (affirm) that I know the contents of this affidavit signed by me and that the statements are true and correct.

Signature of Officer Administering Oath

With a cash surrender value of: