Fillable Printable Affidavit of Support Form Sample

Affidavit of Support Form Sample

Form I-134 02/19/14 Y Page 1

OMB No. 1615-0014; Expires 02/29/2016

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

1. I was born on

(City)

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:

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 Lawful Permanent Resident of the United States, give A-Number

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

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

Gender Age

(Middle Name)

Citizen of (Country) Relationship to SponsorMarital Status

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

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

Child Gender Age

Spouse Age

Child

Child Gender Age

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.

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

Gender

Age

(Date [mm/dd/yyyy]) (Country)

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

Name (Family Name)

(First Name)

, residing at

(Street Number and Name)(Name)

(Zip Code if in U.S.)

(Country)

(State)

(City)

Form I-134, Affidavit of Support

Department of Homeland Security

U.S. Citizenship and Immigration Services

e. If a lawfully admitted nonimmigrant, give Form I-94, Arrival-Departure Record, number

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:

a. 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;

b. 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

c. 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.

(Date [mm/dd/yyyy])

(State)

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Form I-134 02/19/14 Y Page 2

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.)

with7. I am employed as or engaged in the business of

(Name of Concern)(Type of Business)

(Zip Code)

(State)

(City)(Street Number and Name

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:

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

Which is located at:

(Zip Code)(City) (State)

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 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 of Person

I have life insurance in the sum of:

I own real estate valued at:

Date submitted

With a cash surrender value of:

do not intend to make specific contributions to the support of the person(s) named in item 3.

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".

Date submittedRelationshipName of Person

11. I intend

(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.

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

(Street Number and Name)

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