Blank USCIS I-134 Form

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

3.a. In Care Of Name

3.b. Street Number

and Name

3.c. Apt. Ste. Flr.

3.d. City or Town

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.f. Province

5.g. Postal Code

5.h. Country

Other Information

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

7.a. Town or City of Birth

7.b. Country of Birth

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

► A-

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

Part 1. Information About You (the Sponsor)

(continued)

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

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

3. Gender Male Female

4.A-Number (if any)

► A-

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

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.

Part 3. Other Information About the Sponsor

7.a. I have life insurance in the sum of $

Employment Information

I am currently:

1.a. Employed as a/an

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

Current Employer Address (if employed)

2.a. Street Number

and Name

2.b. Apt. Ste. Flr.

2.c. City or Town

2.f. Province

2.g. Postal Code

2.h. Country

Income and Asset Information

(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.b. With a cash surrender value of

$

Real Estate Information

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

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)

Part 3. Other Information About the Sponsor

(continued)

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.)

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.

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)

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.

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.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Certification

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)

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)

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)

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.f. Province

3.g. Postal Code

3.h. Country

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.

Part 7. Additional Information

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.

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

5.d.