Form I-134 Declaration of Financial Support

Declaration of Financial Support

USCIS
Form I-134

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

OMB No. 1615-0014
Expires 07/31/2023

► 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.

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.
1.

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

2.

Given Name (First Name)

Middle Name

Other Names Used
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)

3.

Date of Birth (mm/dd/yyyy)

Given Name (First Name)

4.

Male
6.

5.

Gender
Female

Middle Name

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

Place of Birth
City or Town

State or Province

Country
7.

Country of Citizenship or Nationality

8.

Marital Status
Single, Never Married

Married

Divorced

Widowed

Legally Separated

Marriage Annulled

Other (Explain):

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Part 2. Information about the Beneficiary (continued)
9.

Beneficiary's Mailing Address
In Care Of Name (if any)
Street Number and Name

Apt.Ste. Flr. Number

City or Town

State

Province
10.

Postal Code

ZIP Code

Country

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

Yes

No

If you answered “No” to Item Number 10., provide your physical address in Item Number 11.
11.

Beneficiary's Physical Address
In Care Of Name (if any)
Street Number and Name (Do not provide a PO Box in this space unless it is your ONLY address.) Apt. Ste. Flr. Number
City or Town
Province

State
Postal Code

ZIP Code

Country

Beneficiary's Anticipated Length of Stay
12.

Beneficiary's Anticipated Period of Stay in the United States
From (mm/dd/yyyy)
To (select one):
(mm/dd/yyyy)
No End Date

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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.

Beneficiary's Income
13.

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 16. and not in Item Number 13.
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
Income
(Type or print “Self” if you are filing for contribution to the
yourself as the beneficiary or “Beneficiary” if
beneficiary
someone is agreeing to support you in
annually (if none,
Part 3.)
type or print $0)
$
$
$
$
$
Total Number of Dependents
Total Income $

14.

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)?

15.

If you answered “Yes” to Item Number 14., what amount of the beneficiary's total income comes
from an illegal activity or source?

Form I-134 Edition 01/04/23

Yes

No

$

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Part 2. Information about the Beneficiary (continued)
Beneficiary's Assets
16.

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.
Full Name of Asset Holder
(First, Middle, Last)

Type of Asset

Amount (Cash Value)
(U.S. dollars)

Current Cash Value (U.S. dollars) $
TOTAL (U.S. dollars) $

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.
1.

Current Legal Name (Do not provide a nickname.)
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Other Names Used
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)

3.

Given Name (First Name)

Middle Name

Current Mailing Address
In Care Of Name (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-134 Edition 01/04/23

Postal Code

ZIP Code

Country

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)
4.

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

Yes

No

If you answered “No” to Item Number 4., provide your current physical address in Item Numbers 5.
5.

Physical Address
In Care Of Name (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State
Postal Code

Province

ZIP Code

Country

Other Information
6.

Date of Birth (mm/dd/yyyy)

7.

Place of Birth
City or Town

State or Province

Country
8.

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

9.

USCIS Online Account Number (if any)
►

Immigration Status
10.

What is your current immigration status? Provide documentation as provided in the instructions.
U.S. Citizen
U.S. National
Lawful Permanent Resident A-Number
► ANonimmigrant Form I-94 Arrival-Departure Record Number
►
Other (Explain):

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)
Employment Information
11.

Employment Status
Employed (full-time, part-time, seasonal, self-employed)

Unemployed or Not Employed

Retired

Other (Explain):
If you indicated that you are employed in Item Number 11., provide the information requested in Item Numbers 12. - 13.
12.

13.

A.

I am currently employed as a/an

B.

I am currently self-employed as a/an

Name of Employer

Current Employer's Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Financial Information
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.

Income
14.

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 17. and not in Item Number 14.
Full Name
(First, Middle, Last) (do not include any
individuals named in Part 2.)

Income
Date of Birth Relationship to the Individual Agreeing
(mm/dd/yyyy)
to Financially Support (Type or print Contribution to the
Beneficiary
“Self” for Individual Agreeing to
Annually (if none,
Financially Support the Beneficiary)
type or print $0)
$
$
$
$
$
Total Number of Dependents
Total Income $

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Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)
15.

Does any of the income listed above come from an illegal activity or source (such as proceeds from
illegal gambling or illegal drug sales)?

16.

If you answered “Yes” to Item Number 15., what amount of income comes from an illegal activity? $

Yes

No

Assets
17.

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.
Full Name of Asset Holder
(you or your household member)

Type of Asset

Amount (Cash Value)
(U.S. dollars)

Current Cash Value (U.S. dollars) $
TOTAL (U.S. dollars) $

Financial Responsibility for Other Beneficiaries
18.

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

Yes

No

If you answered “Yes” to Item Number 18., provide the information requested in Item Numbers 19. - 20. If you need additional
space to complete this section, use the space provided in Part 8. Additional Information.
19.

Person 1
Family Name (Last Name)
A-Number
► A-

20.

Given Name (First Name)

Middle Name

Date Submitted (mm/dd/yyyy)

Person 2
Family Name (Last Name)
A-Number

Given Name (First Name)

Middle Name

Date Submitted (mm/dd/yyyy)

► A-

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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
21.

I

intend

do not intend to make specific contributions to the support of the beneficiary named in Part 2.

Explain the contribution. For example, if you intend to furnish room and board, state for how long. If you intend to provide
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. If
you need additional space, use Part 8. Additional Information.

Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form
I-134 on his or her own behalf)
If you are the beneficiary and are filing Form I-134 on your own behalf, complete and sign Part 4.
NOTE: Read the Penalties section of the Form I-134 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.
1.

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

2.

At my request, the preparer named in Part 7.,
this declaration for me based only upon information I provided or authorized.

, prepared

Beneficiary's Contact Information
3.

Beneficiary's Daytime Telephone Number

5.

Beneficiary's Email Address (if any)

4.

Beneficiary's Mobile Telephone Number (if any)

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.

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Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form
I-134 on his or her own behalf) (continued)
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.
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.

Beneficiary's Signature
6.

Beneficiary's Signature

Date of Signature (mm/dd/yyyy)

Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to
Financially Support the Beneficiary
If you are filing Form I-134 on behalf of someone else (the beneficiary listed in Part 2.), complete and sign Part 5.
NOTE: Read the Penalties section of the Form I-134 Instructions before completing this section.

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

2.

, a language in which I am fluent and I understood

At my request, the preparer named in Part 7.,
declaration for me based only upon information I provided or authorized.

, prepared this

Contact Information of Individual Agreeing to Financially Support the Beneficiary
3.

Daytime Telephone Number

5.

Email Address (if any)

Form I-134 Edition 01/04/23

4.

Mobile Telephone Number (if any)

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Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to
Financially Support the Beneficiary (continued)
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.
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.
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)

2.

Interpreter's Business or Organization Name (if any)

Form I-134 Edition 01/04/23

Interpreter's Given Name (First Name)

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Part 6. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

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)

2.

Preparer's Business or Organization Name (if any)

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Preparer's Given Name (First Name)

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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 Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number

Preparer's Statement
7.

A.

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.

B.

I am an attorney or accredited representative and my representation of the individual agreeing to financially support the
beneficiary (which is the beneficiary if filing on behalf of him or herself) in this case
extends
does not extend
beyond the preparation of this declaration.

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.

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

Form I-134 Edition 01/04/23

Date of Signature (mm/dd/yyyy)

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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 (if any) 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.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A.

Given Name (First Name)

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Middle Name

D.

4.

A.
D.

5.

A.
D.

6.

A.
D.

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