Table of Changes - Form

USCIS
Form I-134

Affidavit of Support
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0014
Expires 02/28/2021

► START HERE - Type or print in black ink.

Part 1. Information About You (the Sponsor)

Sponsor's Physical Address

Your Full Name

5.a. Street Number
and Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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5.b.

Apt.

Ste.

Flr.

5.c. City or Town

1.c. Middle Name

5.d. State
5.f.

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)

5.e. ZIP Code

Province

5.g. Postal Code
5.h. Country

Other Information

6.

2.c. Middle Name

Date of Birth (mm/dd/yyyy)

7.a. Town or City of Birth

Sponsor's Mailing Address

7.b. Country of Birth

3.a. In Care Of Name

3.b. Street Number
and Name
3.c.

Apt.

Ste.

Flr.

8.

Alien Registration Number (A-Number) (if any)
► A-

9.

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

10.

USCIS Online Account Number (if any)
►

3.d. City or Town
3.e. State

3.f.

ZIP Code

3.g. Province
3.h. Postal Code
3.i.

Country

4.

Are your mailing address and physical address the same?
No
Yes

If you answered "No" to Item Number 4., provide your
physical address in Item Numbers 5.a. - 5.h.

Form I-134 02/13/19

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

Page 1 of 8

Part 1. Information About You (the Sponsor)
(continued)
11.c.

I derived my U.S. citizenship by another method.
(Provide an explain in Part 7. Additional
Information.)

11.d.

I am a lawful permanent resident of the
United States. My A-Number is

12.

I am

2.

Date of Birth (mm/dd/yyyy)

3.

Gender

4.

A-Number (if any)
► A-

5.

Country of Citizenship or Nationality

6.

Marital Status
Single or Single, Never Married

years of age and have resided in the United

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

Part 2. Sponsor's Biographic Information
1.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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I am a lawfully admitted nonimmigrant. My
Form I-94, Arrival-Departure Record Number is
►

This affidavit is executed on behalf of the following person:

1.c. Middle Name

► A11.e.

Part 3. Information About the Beneficiary

Ethnicity (Select only one box)
Hispanic or Latino

Divorced

Race (Select all applicable boxes)
White
Asian
Black or African American

Widowed

Legally Separated

Marriage Annulled
Other

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander
3.

Height

Feet

4.

Weight

Pounds

5.

Eye Color (Select only one box)
Black

6.

Female

Married

Not Hispanic or Latino
2.

Male

7.

Relationship to Sponsor

Inches

Beneficiary's Physical Address

Blue

Brown

Gray

Green

Maroon

Pink

Hazel
Unknown/Other

8.a. Street Number
and Name
8.b.

Apt.

Ste.

Flr.

8.c. City or Town

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red
Unknown/
Other

8.d. State
8.f.

8.e. ZIP Code

Province

8.g. Postal Code
8.h. Country

Form I-134 02/13/19

Page 2 of 8

Part 3. Information About the Beneficiary
(continued)
Beneficiary's Spouse (accompanying or following
to join beneficiary)

Part 4. Other Information About the Sponsor
Employment Information
I am currently:
1.a.

9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)

Employed as a/an

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

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9.c. Middle Name

1.b.

10.

Date of Birth (mm/dd/yyyy)

11.

Gender

Male

Female

Self employed as a/an

Current Employer Address (if employed)

Beneficiary's Children

2.a. Street Number
and Name

Child 1

2.b.

12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)

Apt.

Ste.

Flr.

2.c. City or Town
2.d. State

12.c. Middle Name

2.f.

13.

Date of Birth (mm/dd/yyyy)

14.

Gender

Male

Child 2
15.a. Family Name
(Last Name)
15.b. Given Name
(First Name)

Female

2.e. ZIP Code

Province

2.g. Postal Code
2.h. Country

Income and Asset Information

3.

15.c. Middle Name
16.

Date of Birth (mm/dd/yyyy)

17.

Gender

Male

Female

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.)
4.

If you need additional space to complete this section, use the
space provided in Part 7. Additional Information.

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.

Form I-134 02/13/19

Page 3 of 8

Part 4. Other Information About the Sponsor
(continued)
7.a.

$

Real Estate Information

This person is:
Wholly Dependent On Me For Support
Partially Dependent On Me For Support

I have life insurance in the sum of $

7.b. With a cash surrender value of

8.a.

17.

18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name

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I own real estate valued at

$

19.

Relationship to Me:

20.

Date of Birth (mm/dd/yyyy)

21.

This person is:
Wholly Dependent On Me For Support

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.

9.c. City or Town
9.d. State

Partially Dependent On Me For Support

Ste.

Flr.

9.e. ZIP Code

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:

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.

24.a. Family Name
(Last Name)
24.b. Given Name
(First Name)

24.c. Middle Name
25.

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)

Date Submitted (mm/dd/yyyy)

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)

14.c. Middle Name
15.

Relationship to Me:

16.

Date of Birth (mm/dd/yyyy)

Form I-134 02/13/19

Page 4 of 8

Part 4. Other Information About the Sponsor
(continued)

Part 5. Sponsor's Statement, Contact
Information, Certification, and Signature

30.a. Family Name
(Last Name)
30.b. Given Name
(First Name)

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

Sponsor's Statement

30.c. Middle Name
31.

Relationship to Me:

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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.

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.

1.b.

The interpreter named in Part 5. read to me every
question and instruction on this affidavit and my
answer to every question in
,

a language in which I am fluent and I understood
everything.

2.

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

Relationship to Me:

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

36.

Date of Birth (mm/dd/yyyy)

37.

Date of Filing (mm/dd/yyyy)

38.

do not intend to make specific
I
intend
contributions to the support of the person(s) named in
Part 2.

Sponsor's Contact Information

(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.)

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.

Form I-134 02/13/19

Page 5 of 8

Part 5. Sponsor's Statement, Contact
Information, Certification, and Signature
(continued)
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.

Part 6. 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)

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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.

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.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

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)

Sponsor's Signature
6.a. Sponsor's Signature

Interpreter's Certification
I certify, under penalty of perjury, that:

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.

Form I-134 02/13/19

,
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.
Page 6 of 8

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

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

7.a. Interpreter's Signature

5.

Preparer's Fax Number

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

6.

Preparer's Email Address (if any)

Interpreter's Signature

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Part 7. 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)

Preparer's Statement

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.

7.b.

I am an attorney or accredited representative and my
representation of the sponsor in this case
does not extend beyond the
extends
preparation of this affidavit.
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.

Preparer's Certification

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

3.c. City or Town
3.d. State
3.f.

Province

Ste.

Flr.

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.

3.e. ZIP Code

Preparer's Signature
8.a. Preparer's Signature

3.g. Postal Code
3.h. Country
8.b. Date of Signature (mm/dd/yyyy)

Form I-134 02/13/19

Page 7 of 8

5.a. Page Number

Part 8. 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.

Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

3.d.

3.b. Part Number

6.a. Page Number

3.c. Item Number

4.b. Part Number

4.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

7.a. Page Number

4.a. Page Number

5.c. Item Number

5.d.

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A-Number (if any)
► A-

3.a. Page Number

5.b. Part Number

7.d.

4.d.

Form I-134 02/13/19

Page 8 of 8