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

I-134, Affidavit of Support

(Answer All Items: Type or Print in Black Ink.)

I, residing at

(Name) (Street and Number)

(Zip Code if in U.S.)

1. I was born on

(City) (Country)

If you are not a native born United States citizen, answer the following as appropriate:

a. If a United States citizen through naturalization, give certificate of naturalization number

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

c. If United States 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. That I am years of age and have resided in the United States since (date)

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

Name (Family Name) (First Name) (Middle Name) Gender Age

Citizen of (Country) Marital Status Relationship to Sponsor

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

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

Child Gender Age

Child Gender Age

Child Gender Age

Spouse Age

Child

Child Gender Age

4.

5.

6.

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

(Type of Business) (Name of Concern)

at

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

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

I have other personal property, the reasonable value which is $

U.S. Department of Homeland Security

Bureau of Citizenship and Immigration Services

(State) (Country)

at

BEING DULY SWORN DEPOSE AND SAY:

That this affidavit is made by me for the purpose of assuring the United States Government that the person(s) named in 

item 3 will not become a public charge in the United States.

That 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.

That 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.

$

$

(City)

Gender

Gender

Age

(Date-mm/dd/yyyy)

Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04)
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) (Street and Number) (City) (State)

8.

Name of Person Wholly Dependent Partially Dependent Age Relationship to Me

9. That I have previously submitted affidavit(s) of support for the following person(s). If none, state "None.''

Name

10. That I have submitted visa petition(s) to the Bureau of Citizenship and Immigration Services (CIS) on behalf of the 

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

Name Relationship Date submitted

11. That 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 United States dollars and state whether it is to be 

given in a lump sum, weekly or monthly, or for how long.)

Oath or Affirmation of Sponsor

I acknowledge that I have read Part III of the Instructions, Sponsor and Alien Liability, and am aware of my

responsibilities as an immigrant sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.

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

Signature of sponsor

Subscribed and sworn to (affirmed) before me this day of

at . My commission expires on

Signature of Officer Administering Oath 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.

(Signature) (Address) (Date)

I have life insurance in the sum of

With a cash surrender value of

I own real estate valued at

$

$

$

$

That 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. 06/17/04)N (Prior versions may be used until 09/30/04) Page 2
I-134, Affidavit of Support

Instructions

An alien applying for SSI must make available to the Social 

Security Administration documentation concerning his or 

her income and resources and those of the sponsor, 

including information that was provided in support of the 

application for an immigrant visa or adjustment of status. 

An alien applying for TANF or Food Stamps must make 

similar information available to the State public assistance 

agency. 

The Secretary of Health and Human Services and the 

Secretary of Agriculture are authorized to obtain copies of 

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

Department of State and to release such documentation to a 

State public assistance agency.

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:

Sections 1621(e) and 415(d) 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 misinformation provided by 

a sponsor or because of a sponsor's failure to provide 

information. 

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, except that the sponsor was without fault or 

where good cause existed.

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

 institution where you have deposits, giving the 

 following details regarding your account:

1. Date account opened;

2. Total amount deposited for the past year;

3. Present balance.

B. Statement of your employer on business stationery, 

 showing:

1. Date and nature of employment;

2. Salary paid;

3. Whether the position is temporary or permanent.

C. If self-employed:

1. Copy of last income tax return filed; or

2. Report of commercial rating concern.

D. List containing serial numbers and denominations of 

 bonds and name of record owner(s).

U.S. Department of Homeland Security

Bureau of Citizenship and Immigration Services

I. Execution of Affidavit.

II. Supporting Evidence.

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

Social Security Act establish 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, 

amendments 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. 06/17/04)N (Prior versions may be used until 09/30/04)

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 the 

Bureau of Citizenship and Immigration Services 

(CIS) 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 affirmed before a U.S. 

consular or immigration officer.

Joint and Several Liability Issues.

Documentation on Income and Resources.
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. Our legal right to 

ask for this information is in 8 U.S.C. 1203 and 1225. 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.

It 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 CIS functions. 

Failure to provide the information may result in the denial of 

the alien's application for a visa or his or her removal from 

the United States.

Form I-134 (Rev. 06/17/04)N (Prior versions may be used until 09/30/04) Page 2

V. Information and CIS Forms.

For information on immigration laws, regulations and 

procedures or to order CIS forms, call our National 

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

our website at www.uscis.gov.

An agency may not conduct or sponsor a collection of 

information and a person is not required to respond to a 

collection of information unless it displays a currently valid 

OMB control number. We try to create forms and 

instructions that are accurate, can be easily understood and 

that 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 application is 30 minutes per 

application, including the time to learn about the law and the 

form, complete the form, and assemble and submit the 

Affidavit. If you have comments regarding the accuracy of 

this estimate or suggestions for making this form simpler, 

write to the Bureau of Citizenship and Immigration Services, 

Regulations and Forms Services Division (HQRFS), 425 I 

Street, N.W., Room 4034, Washington, D.C. 20529; OMB 

No. 1615-0014. Do not mail your completed application to 

this address.

VII. Paperwork Reduction Act Notice.

Authority for the collection of the information requested on 

this form is contained in 8 U.S.C. 1182(a)(15),1184(a) and 

1258.

 The information will be used principally by the CIS, 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. 

IV. Authority, Use and Penalties.

These provisions do not apply to the 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. 

The provisions also do not apply to the SSI or Food Stamp 

eligibility of an alien who becomes blind or disabled after 

admission to the United States for permanent residency.