Form I-134A Edition 07/11/23 Page 1 of 14

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S U B M I T

Online Request to be a Supporter and 

Declaration of Financial Support 

Department of Homeland Security 

U.S. Citizenship and Immigration Services 

USCIS 

Form I-134A 

► START HERE - Type or print in black ink. 

Part 1. Basis for Filing

1. I am filing this form on behalf of: Myself as the beneficiary.

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

M F

Another individual who is the beneficiary.

Part 2. Information about the Beneficiary

Complete Part 2. regardless of whether you are filing this form on behalf of yourself as the beneficiary or on behalf of another 

individual who is the beneficiary.

Family Name (Last Name) Given Name (First Name) Middle Name 

1. Beneficiary's Current Legal Name (Do not provide a nickname.)

Provide all other names the beneficiary has ever used, including aliases, maiden name, and nicknames. If you need extra space 

to complete this section, use the space provided in Part 8. Additional Information.

Family Name (Last Name) Given Name (First Name) Middle Name

6. Sex

► A7. Alien Registration Number (A-Number) 

2. Other Names Used

3.

X

If "Family Reunification Program" selected in Item Number 2.

I am filing for an individual under the parole process for the following country

5. Invitation Number:

How many total family members will be included in this family reunification group 

who all share the same invitation number?

6.

2. I am filing this form under one of the following:

If "Family Reunification Program" selected in Part 1., Item Number 2. Is this the individual listed as the 

principal beneficiary in your Family Reunification Parole Process invitation letter?

3. Yes No

If "Parole Process" selected in Item Number 2.

4. I am filing for my relative who is associated with an approved I-130 and a national of:

A grant of parole is a discretionary determination granted on a case-by-case basis for urgent humanitarian reasons or significant 

public benefit. Please explain why a favorable exercise of discretion is merited for this individual.

4.
Form I-134A Edition 07/11/23 Page 2 of 14

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Part 2. Information about the Beneficiary (continued)

12. Beneficiary's Mailing Address

In Care Of Name 

Yes No

City or Town State ZIP Code 

Street Number and Name (Do not provide a PO Box in this space unless it is your ONLY address.) Apt. Ste. Flr. Number

Province Postal Code Country 

In Care Of Name

Street Number and Name Apt.Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

13. Are the beneficiary's mailing address and physical address the same?

If you answered “No” to Item Number 13., provide your physical address in Item Number 14.

14. Beneficiary's Physical Address

17. Beneficiary's Email Address (if any)

15. Beneficiary's Daytime Telephone Number 16. Beneficiary's Mobile Telephone Number (if any)

Single, Never Married Married Divorced Widowed Legally Separated Marriage Annulled 

Other (Explain):

11. Marital Status

10. Passport Number of the beneficiary's most recently issued passport

Expiration date for the most recently issued passport (mm/dd/yyyy)

Country that issued the most recently issued passport

9. Country of Citizenship or Nationality 

8. Place of Birth

Country

City or Town State or Province
Form I-134A Edition 07/11/23 Page 3 of 14

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Part 2. Information about the Beneficiary (continued)

Beneficiary's Financial Information

Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this 

section, use the space provided in Part 8. Additional Information.

Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any 

other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about 

assets that are not based on employment should be added in Item Number 24. and not in Item Number 19.

19.

Individual's Full Name 

(First, Middle, Last) (do not include any 

individuals named in Part 3.)

Date of Birth 

(mm/dd/yyyy)

Relationship to the Beneficiary 

(Type or print “Self” if you are filing for 

yourself as the beneficiary or 

“Beneficiary” if someone is agreeing to 

support you in Part 3.)

Income contribution 

to the beneficiary 

annually (if none, 

type or print $0)

Yes No

Yes No

$

$

$

$

$

Total Number of Dependents

Total Income $

Does any of the beneficiary's total income come from means-tested public benefits as defined in 

8 CFR 213a.1?

22.

$ If you answered “Yes” to Item Number 22., what amount of the beneficiary's total income 

comes from means-tested public benefits?

23.

Does any of the beneficiary's total income (including income from dependents and other 

individuals who contribute to the beneficiary's income, excluding any individuals named in Part 3.) 

come from an illegal activity or source (such as proceeds from illegal gambling or illegal drug 

sales)?

20.

$ If you answered “Yes” to Item Number 20., what amount of the beneficiary's total income comes 

from an illegal activity or source? (Type or print “N/A” if you answered “No” to Item Number 20.)

21.

Beneficiary's Income

Beneficiary's Anticipated Length of Stay

18. Beneficiary's Anticipated Period of Stay in the United States

(mm/dd/yyyy)

No End Date

To (select one):

From (mm/dd/yyyy)
Form I-134A Edition 07/11/23 Page 4 of 14

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2.

If you are not the beneficiary named in Part 2., complete Part 3. 

Current Legal Name (Do not provide a nickname.)

Family Name (Last Name) Given Name (First Name) Middle Name

1.

Provide 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 8. Additional Information.

Family Name (Last Name) Given Name (First Name) Middle Name

2. Other Names Used

3. If "Parole Process" selected in Part 1., Item Number 2. Provide the name of the organization, group, or individual that is 

providing support to the beneficiary with you (if any)

Organization, Group, Individual Name

Part 2. Information about the Beneficiary (continued)

In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay 

(excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets.

24.

Type of Asset Amount (Cash Value) 

(U.S. dollars)

 TOTAL (U.S. dollars)

Full Name of Asset Holder 

(First, Middle, Last)

$

Beneficiary's Assets

If "Family Reunification Program" selected in Part 1., Item Number 2. Provide the name of the individual(s) or co-sponsor(s) 

that is providing support to the beneficiary with you (if any).

4.

Individual(s) or Co-sponsor(s) Name
Form I-134A Edition 07/11/23 Page 5 of 14

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6. Is your current mailing address the same as your current physical address?

If you answered “No” to Item Number 6., provide your current physical address in Item Number 7.

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2. (continued)

Other Information

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

Yes No

In Care Of Name

City or Town State ZIP Code

Street Number and Name Apt.Ste. Flr. Number

Province Postal Code Country

7. Physical Address

10.

► A11. Alien Registration Number (A-Number) 12. USCIS Online Account Number

►

Place of Birth

Country

City or Town State or Province

14. What is your relationship to the beneficiary?

9. Sex M F

Social Security Number

►

13.

X

5. Current Mailing Address

In Care Of Name

City or Town State ZIP Code

Street Number and Name Apt.Ste. Flr. Number

Province Postal Code Country
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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2. (continued)

16. Employment Status 

Employed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed Retired

Other (Explain):

17. I am currently employed as a/an Name of Employer

I am currently self-employed as a/an

City or Town State ZIP Code

Street Number and Name Apt.Ste. Flr. Number

Province Postal Code Country

18. Current Employer's Address

A.

B.

Employment Information

If you indicated that you are employed in Item Number 16., provide the information requested in Item Numbers 17. - 18.

U.S. Citizen

U.S. National

Lawful Permanent Resident

Nonimmigrant

Immigration Status

15. What is your current immigration status? Provide documentation as provided in the instructions.

Form I-94 Arrival-Departure Record Number

►

Other (Explain):
Form I-134A Edition 07/11/23 Page 7 of 14

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2. (continued)

Does any of the income listed above come from an illegal activity or source (such as proceeds from 

illegal gambling or illegal drug sales)?

Yes No

Yes No

20.

$

Does any of the income listed above come from means-tested public benefits as defined in 8 CFR 

213a.1?

22.

If you answered “Yes” to Item Number 22., what amount of income is from means-tested 

public benefits?

$ 23.

24. Fill out the table below regarding the assets available to you (do not include any assets from any individuals named in Part 2.). 

Attach evidence showing you have these assets.

Type of Asset Amount (Cash Value) 

(U.S. dollars)

 TOTAL (U.S. dollars)

Full Name of Asset Holder 

(you or your household member)

$

Assets

If you answered “Yes” to Item Number 20., what amount of income comes from an illegal activity? 

(Type or print “N/A” if you answered “No” to Item Number 20.)

21.

Total Number of Dependents

Financial Information

Income

Relationship to the Individual Agreeing 

to Financially Support (Type or print 

“Self” for Individual Agreeing to 

Financially Support the Beneficiary)

Income 

Contribution to the 

Beneficiary 

Annually (if none, 

type or print $0)

$

$

$

$

$

Total Income $

Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you 

financially support (do not include any individuals named in Part 2.). Information about assets that are not based on 

employment should be added in Item Number 24. and not in Item Number 19.

19.

Full Name 

(First, Middle, Last) (do not include any 

individuals named in Part 2.)

Date of Birth 

(mm/dd/yyyy)

Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the 

space provided in Part 8. Additional Information.
Form I-134A Edition 07/11/23 Page 8 of 14

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2. (continued)

Intent to Provide Specific Contributions to the Beneficiary

28. You are responsible for receiving, maintaining, and supporting the beneficiary for the duration of their temporary stay in the 

United States. Describe the resources you plan to use or provide to ensure the beneficiary has adequate financial support to 

cover their basic living needs.

29. You are responsible for ensuring that the beneficiary has safe and appropriate housing for the duration of their parole in the 

United States. Describe how you will ensure that the beneficiary's housing needs are met, including where the beneficiary will 

reside during their temporary stay in the United States, if known. 

If you answered “Yes” to Item Number 25., provide the information requested in Item Numbers 26. - 27. If you need additional 

space to complete this section, use the space provided in Part 8. Additional Information.

26. Person 1

Family Name (Last Name) Given Name (First Name) Middle Name

A-Number 

► ADate Submitted (mm/dd/yyyy)

27. Person 2

Family Name (Last Name) Given Name (First Name) Middle Name

A-Number 

► ADate Submitted (mm/dd/yyyy)

Yes No

Financial Responsibility for Other Beneficiaries

Have you previously submitted a Form I-134A on behalf of a person other than the beneficiary 

named in Part 2?

25.
Form I-134A Edition 07/11/23 Page 9 of 14

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Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (Only complete 

this section if Part 1. Basis for Filing selection is "Myself as the beneficiary", otherwise continued to Part 5.)

If you are the beneficiary and are filing Form I-134A on your own behalf, complete and sign Part 4.

NOTE: Read the Penalties section of the Form I-134A Instructions before completing this section.

Beneficiary's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

I, as the beneficiary, certify the following:

A. I can read and understand English, and I have read and understand every question and instruction on this declaration 

and my answer to every question.

B. The interpreter named in Part 6. read to me every question and instruction on this declaration and my answer to every 

, a language in which I am fluent and I understood 

2. At my request, the preparer named in Part 7., , prepared 

this declaration for me based only upon information I provided or authorized.

1.

question in 

everything.

Beneficiary'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 and all 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 declaration, 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 declaration;

2) I understood all of the information contained in, and submitted with, my declaration; and

3) All of this information was complete, true, and correct at the time of filing.

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in 

Part 2. (continued)

30. You are responsible for assisting the beneficiary's access to available services and benefits such as learning English, securing 

employment opportunities once authorized to work, enrolling children in school, and helping to enroll for benefits for which 

they are eligible. Describe what steps you plan to take as part of these responsibilities.
Form I-134A Edition 07/11/23 Page 10 of 14

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Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to 

Financially Support the Beneficiary

NOTE: Read the Penalties section of the Form I-134A Instructions before completing this section. 

If you are filing Form I-134A on behalf of someone else (the beneficiary listed in Part 2.), complete and sign Part 5.

Statement of Individual Agreeing to Financially Support the Beneficiary

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

1. I, as the individual agreeing to financially support the beneficiary, certify the following:

A. I can read and understand English, and I have read and understand every question and instruction on this declaration 

and my answer to every question.

B. The interpreter named in Part 6. read to me every question and instruction on this declaration and my answer to every 

question in , a language in which I am fluent and I understood. 

2. At my request, the preparer named in Part 7., , prepared this

declaration for me based only upon information I provided or authorized.

Contact Information of Individual Agreeing to Financially Support the Beneficiary

5. Email Address (if any)

3. Daytime Telephone Number 4. Mobile Telephone Number (if any)

Certification of Individual Agreeing to Financially Support the Beneficiary

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 and all 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 declaration, 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 law.

Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (Only complete 

this section if Part 1. Basis for Filing selection is "Myself as the beneficiary", otherwise continued to Part 

5.) (continued)

Beneficiary's Signature

3. Beneficiary's Signature Date of Signature (mm/dd/yyyy) 

I certify, under penalty of perjury, that I provided or authorized all of the information in my declaration, I understand all of the 

information contained in, and submitted with, my declaration, and that all of this information is complete, true, and correct.

That this declaration is made by me to assure the U.S. Government that I will be able to financially support myself while in the United 

States.

That I am willing and able to pay for necessary expenses for the duration of my temporary stay in the United States.
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Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to 

Financially Support the Beneficiary (continued)

I certify, under penalty of perjury, that I provided or authorized all of the information in my declaration, I understand all of the 

information contained in, and submitted with, my declaration, and that all of this information is complete, true, and correct.

That this declaration is made by me to assure the U.S. Government that the person named in Part 2. will be financially supported 

while in the United States.

That I am willing and able to receive, maintain, and support the person named in Part 2. to better ensure that such persons will have 

sufficient financial resources or financial support to pay for necessary expenses for the period of his or her temporary stay in the 

United States.

I acknowledge that I have read this section, and I am aware of my responsibilities as an individual agreeing to financially support the 

beneficiary.

Signature of Individual Agreeing to Financially Support the Beneficiary

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

NOTE TO ALL INDIVIDUALS AGREEING TO FINANCIALLY SUPPORT THE BENEFICIARY: If you do not completely 

fill out this declaration or if you fail to submit required documents listed in the Instructions, USCIS or the Department of State may 

deny or not consider your declaration.

Part 6. Interpreter's Contact Information, Certification, and Signature 

Provide the following information about the interpreter.

Interpreter's Full Name

1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)

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

Interpreter's Mailing Address

3. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

2) I understood all of the information contained in, and submitted with, my declaration; and

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 declaration;

3) All of this information was complete, true, and correct at the time of filing.
Form I-134A Edition 07/11/23 Page 12 of 14

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Part 6. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and which is the same language specified in Part 4.

or in Part 5., Item B. in Item Number 1., and I have read to this individual agreeing to financially support the beneficiary in the 

identified language every question and instruction on this declaration and his or her answer to every question. The individual agreeing 

to financially support the beneficiary informed me that he or she understands every instruction, question, and answer on the 

declaration, including the Certification of the Individual Agreeing to Financially Support the Beneficiary, and has verified the 

accuracy of every answer.

Interpreter's Signature

7. Interpreter's Signature Date of Signature (mm/dd/yyyy) 

Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if 

Other Than the Individual Agreeing to Financially Support the Beneficiary

Provide the following information about the preparer.

Preparer's Full Name 

1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)

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

Country

Preparer's Mailing Address

3. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code

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) 
Form I-134A Edition 07/11/23 Page 13 of 14

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Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if 

Other Than the Individual Agreeing to Financially Support the Beneficiary (continued)

Preparer's Statement

7. A.

B.

I am not an attorney or accredited representative but have prepared this declaration on behalf of the individual agreeing 

to financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself) and with that 

individual's consent.

I am an attorney or accredited representative and my representation of the individual agreeing to financially support the 

beyond the preparation of this declaration.

extends

NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of 

Appearance as Attorney or Accredited Representative, with this application.

beneficiary (which is the beneficiary if filing on behalf of him or herself) in this case 

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this declaration at the request of the individual agreeing to 

financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself). The individual agreeing to 

financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself) then reviewed this completed 

declaration and informed me that he or she understands all of the information contained in, and submitted with, his or her declaration, 

including the Certification of the Individual Agreeing to Financially Support the Beneficiary, and that all of this information is 

complete, true, and correct. I completed this declaration based only on information that the individual agreeing to financially support 

the beneficiary provided to me or authorized me to obtain or use.

Preparer's Signature 

8. Preparer's Signature Date of Signature (mm/dd/yyyy) 

does not extend 

Preparer's Contact Information

4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number 

6. Preparer's Email Address (if any)
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Part 8. Additional Information

If you need extra space to provide any additional information within this declaration, 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 declaration or attach a separate sheet of paper. 

Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to 

which your answer refers; and sign and date each sheet.

►AD.

1.

A. Page Number B. Part Number C. Item Number

2. A-Number

D.

A. Page Number B. Part Number C. Item Number

Family Name (Last Name) Given Name (First Name) Middle Name 

D.

A. Page Number B. Part Number C. Item Number

D.

A. Page Number B. Part Number C. Item Number

3.

4.

5.

6.