Fillable Printable Form I-134

What is a Form I-134 ?

Form I-134, whose full name is Affidavit of Support, is a form submitted to the United States Citizenship and Immigration Services used by foreign nationals to show that visa applicants have sponsorship and will not become public charges while in the United States. Filling out form i-134 affidavit of support to help a U.S. Visa applicant. Following a fillable Form I-134. Edit, sign and print it at Handypdf.com.

Fillable Printable Form I-134

What is a Form I-134 ?

Form I-134

Form I-134 11/30/16 N Page 1 of 8

Affidavit of Support

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-134

OMB No. 1615-0014

Expires 11/30/2018

► START HERE - Type or print in black ink.

Part 1. Information About You (the Sponsor)

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

Your Full 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.d.

3.e.

3.b.

3.c.

3.h.

3.i.

3.g.

City or Town

State 3.f. ZIP Code

Postal Code

Province

Country

Street Number

and Name

Apt. Ste. Flr.

In Care Of Name

3.a.

4. Are your mailing address and physical address the same?

Yes

If you answered "No" to Item Number 4., provide your

physical address in Item Numbers 5.a. - 5.h.

Sponsor's Physical Address

5.b.

5.c.

5.a.

5.f.

5.g.

5.d.

5.h.

City or Town

State 5.e. ZIP Code

Postal Code

Province

Country

Street Number

and Name

Ste. Flr.

Apt.

Other Information

6. Date of Birth (mm/dd/yyyy)

7.a. Town or City

of Birth

U.S. Social Security Number (if any)9.

►

USCIS Online Account Number (if any)10.

►

A-

►

Alien Registration Number (A-Number) (if any)8.

7.b. Country

of Birth

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:

Citizenship or Residency or Status

11.a.

I am a U.S. citizen through parent(s) or marriage.

My Certificate of Citizenship number is

11.b.

I am a U.S. citizen through naturalization. My

Certificate of Naturalization number is

Form I-134 11/30/16 N Page 2 of 8

Part 1. Information About You (the Sponsor)

(continued)

I derived my U.S. citizenship by another method.

(Provide an explain in Part 7. Additional

Information.)

11.c.

11.d.

I am a lawfully admitted nonimmigrant. My

Form I-94, Arrival-Departure Record Number is

11.e.

I am a lawful permanent resident of the

United States. My A-Number is

12.

Part 2. Information About the Beneficiary

I am

States since (Date) (mm/dd/yyyy)

years of age and have resided in the United

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)

Male Female3. Gender

A-

►

A-Number (if any)4.

5. Country of Citizenship or Nationality

8.c.

8.d.

8.a.

8.b.

8.g.

8.h.

8.f.

City or Town

State 8.e. ZIP Code

Postal Code

Province

Country

Street Number

and Name

Ste. Flr.

Apt.

A-

►

Marital Status6.

Married

Legally Separated

Widowed

Single or Single, Never Married

Divorced

Other

Marriage Annulled

Relationship to Sponsor

Beneficiary's Physical Address

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)

Gender14. FemaleMale

Male Female11. 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)

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)

Gender17. FemaleMale

If you need additional space to complete this section, use the

space provided in Part 7. Additional Information.

Form I-134 11/30/16 N Page 3 of 8

Part 3. Other Information About the Sponsor

Employment Information

1.b.

I am currently:

Employed as a/an1.a.

1.a.1.Name of Employer (if applicable)

Self employed as a/an

Current Employer Address (if employed)

2.c.

2.d.

2.a.

2.b.

2.g.

2.h.

2.f.

City or Town

State 2.e. ZIP Code

Postal Code

Province

Country

Street Number

and Name

Ste. Flr.Apt.

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.)

5. Value of my other personal property

Balance of all my savings and checking accounts in

United States-based financial institutions

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. $

7.b. With a cash surrender value of

I have life insurance in the sum of

Real Estate Information

8.a. $

8.b. I have mortgages or other debts amounting to

I own real estate valued at

My real estate is located at:

9.c.

9.d.

9.a.

9.b.

City or Town

State 9.e. ZIP Code

Street Number

and Name

Ste. Flr.Apt.

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:

Date of Birth (mm/dd/yyyy)

13.

Wholly Dependent On Me For Support

Partially Dependent On Me For Support

12.

This person is:

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)

Form I-134 11/30/16 N Page 4 of 8

Part 3. Other Information About the Sponsor

(continued)

17.

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

This person is:

19.

Date of Birth (mm/dd/yyyy)

20.

Relationship to Me:

21.

Wholly Dependent On Me For Support

This person is:

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

Date Submitted (mm/dd/yyyy)23.

24.a. Family Name

(Last Name)

24.b. Given Name

(First Name)

24.c.

Middle Name

Date Submitted (mm/dd/yyyy)25.

33. Date of Filing (mm/dd/yyyy)

32.

Date of Birth (mm/dd/yyyy)

31. Relationship to Me:

Middle Name

30.c.

Given Name

(First Name)

30.b.

Family Name

(Last Name)

30.a.

Date of Birth (mm/dd/yyyy)28.

Date of Filing (mm/dd/yyyy)29.

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

Relationship to Me:27.

37.

38. I intend

Date of Filing (mm/dd/yyyy)

36.

Date of Birth (mm/dd/yyyy)

35. Relationship to Me:

Middle Name

34.c.

Given Name

(First Name)

34.b.

Family Name

(Last Name)

34.a.

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.)

do not intend to make specific

Form I-134 11/30/16 N Page 5 of 8

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.

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.

Sponsor's Statement

The interpreter named in Part 5. read to me every

question and instruction on this affidavit and my

answer to every question in

1.b.

a language in which I am fluent and I understood

everything.

At my request, the preparer named in Part 6.,2.

Sponsor's Email Address (if any)

Sponsor's Mobile Telephone Number (if any)4.

Sponsor's Daytime Telephone Number3.

Sponsor's Contact Information

prepared this affidavit for me based only upon

information I provided or authorized.

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 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 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.

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.

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.

Sponsor's Signature6.a.

6.b. Date of Signature (mm/dd/yyyy)

Sponsor's Signature

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.

Form I-134 11/30/16 N Page 6 of 8

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.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

Interpreter's Business or Organization Name (if any)2.

Part 5. Interpreter's Contact Information,

Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f.

Postal Code3.g.

Province

3.h. Country

Street Number

and Name

3.a.

3.b.

Ste. Flr.Apt.

Interpreter's Daytime Telephone Number

5. Interpreter's Mobile Telephone Number (if any)

Interpreter's Email Address (if any)

Interpreter's Contact Information

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and

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.

7.b.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Statement,

Declaration, and Signature of the Person

Preparing this Affidavit, if Other Than the

Sponsor

Preparer's Full Name

Provide the following information about the preparer.

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

Preparer's Business or Organization Name (if any)2.

Preparer's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

3.f.

Postal Code3.g.

Province

3.h. Country

Street Number

and Name

3.a.

3.b.

Ste. Flr.Apt.

Form I-134 11/30/16 N Page 7 of 8

Preparer's Contact Information

Preparer's Daytime Telephone Number

Preparer's Email Address (if any)

Preparer's Fax Number 5.

Preparer's Statement

I am an attorney or accredited representative and my

representation of the sponsor in this case

I am not an attorney or accredited representative but

have prepared this affidavit on behalf of the sponsor

and with the sponsor's consent.

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.

7.a.

7.b.

extends

does not extend beyond the

preparation of this affidavit.

Part 6. Contact Information, Statement,

Declaration, and Signature of the Person

Preparing this Affidavit, if Other Than the

Sponsor (continued)

Preparer's Certification

Preparer's Signature

Preparer's Signature8.a.

8.b. Date of Signature (mm/dd/yyyy)

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.

Form I-134 11/30/16 N Page 8 of 8

Part 7. Additional Information

3.d.

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)

1.b. Given Name

(First Name)

1.c.

Middle Name

2. A-Number (if any)

3.a.

Page Number

3.b. Part Number 3.c. Item Number

6.a.

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

6.d.

4.d.

4.a.

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

5.d.

5.a.

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

A-

►

7.a.

Page Number

7.b. Part Number 7.c. Item Number

7.d.