Affidavit of Support Form - New Jersey

Department of Homeland Security
U S Cltazenshlp and Immigration Services
OMB No 1615-0014
Form 1-134, Affidavit of Support
(Name)
(Answer all items. Type or print in black ink.)
residing at
(Street Number and Name)
Citazen of (Country)
Presently resades at (Street Number and Name)
(Date-mm/dd/yyyy)
(Middle Name) Gender Age
Relationship to Sponsor
(State) (Country)
Marital Status
(City)
(Caty) (State) (Country)
certify under penalty of perjury under U.S. law, that:
I I was born on in
(Date-mm!dd/yyyy) (Caty) (State) (Country)
If you are not a U S catizen based on your birth an the United States, or a non-citizen U S. national based on your birth m American Samoa (including
Swains Island), answer the following as appropriate
a. If a U S cmzen through naturalization, gave Certificate of Naturalizataon number
b. If a U.S cmzen through parent(s) or marnage, gave Certaficate of Clhzenshmp number
e. IfU.S citizenship was derived by some other method, attach a statement of explanation
d. Ifa Lawful Permanent Resxdent of the United States, give A-Number
e. Ifa lawfully admitted nonmarmgrant, give Form 1-94, Arraval-Departure Record, number
2. I am __ years of age and have resided in the Umted States since
3. Thas affidavit is executed on behalf of the following person"
Name (Family Name) (Farst Name)
(Zap Code ffmU S )
Name of spouse and children accompanying or following to join person"
Spouse Gender Age Child
Gender Age
Child Gender Age Child Gender Age
Child Gender Age Child Gender Age
4. This affidavat is made by me for the purpose of assuring the U S Government that the person(s) named an item (3) wall not become a pubhc
charge in the United States
5. I am walling and able to receive, mamtain, and support the person(s) named In item 3 I am ready and wflhng 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 Umted States, or to guarantee that the above named
person(s) wall maintain his or her nonlmmxgrant status, if admitted temporarily, and wall depart prior to the expiration of his or her authorized stay
m the Umted States.
6,
I understand that"
a. Form 1-134 as an "undertaking" under sectmn 213 of the Immigration and Nationality Act, and I may be sued if the person(s) named m item 3
becomes a pubhc charge after admlssaon to the United States;
b. Form 1-134 may be made available to any Federal, State, or local agency that may reemve an application from the person(s) named in item 3
for Food Stamps, Supplemental Security Income, or Temporary Assistance to Needy Families; and
e. If the person(s) named m item 3 does apply for Food Stamps, Supplemental Security Income, or Temporary Asmstance for Needy Fanuhes,
my own income and assets may be considered an deciding the person's application How long my ancome and assets may be attrabuted to the
person(s) named an item 3 is determined under the statutes and rules governing each specific program
Form 1-134 (Rev 05/25/11) Y
Page 1/2
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Affidavit of Support Form - New Jersey PDF

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