Affidavit of Support Form - New Jersey
7. I am employed as or engaged in the busmess of
(Type of Business)
with
(Name of Concern)
at
(Street Number and Name (City)
I derwe an annual income of (If self-employed, I have attached a copy of my last income tax return or
report of commercial ratmg 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 m the Umted States $
I have other personal property, the reasonable value ofwhach is' $
I have stocks and bonds wlth the following market value, as indicated on the attached hst, which I certify
to be true and correct to the best of my knowledge and belief $
I have life insurance in the sum of. $
With a cash surrender value of $
I own real estate valued at. $
With mortgage(s) or other encumbrance(s) thereon amounting to $
(State) (Zlp Code)
Which is located at.
(Street Number and Name) (City) (State) (Zip Code)
8. The followmg persons are dependent upon me for support. (Check the box m the appropriate column to indicate whether the person named is
wholly or partially dependent upon you for support )
Name of Person
[] []
[] []
[] []
9. I have prevxously submgted affidavit(s) of support for the following person(s) If none, state "None"
Name of Person
Wholly Dependent Partially Dependent Age Relationship to Me
Date submitted
10. I have submitted a visa petatxon(s) to U S Citizenship and Immigration Services on behalf of the following person(s) If none, state "None"
Name of Person Relationship Date submitted
11. I [] intend [] do not intend to make specific contrlbutxons to the support of the person(s) named m item 3
(lf you check "intend," indicate the exact nature and duration of the contributions For example, if you intend to furmsh room and board, state
for how long and, if money, state the amount m US dollars and whether ttts to be given m a lump sum, weekly or monthly, and for how long
Oath or Affirmation of Sponsor
I acknowledge that I have read "Sponsor and Alien Liability" on Page 2 of the instructions for this form, and am aware of my
responsibilities as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.
I certify under penalty of perjury under United States law that I know the contents of this affidavit signed by me and that the statements are
true and correct. °
Signature of Sponsor Date
Form 1-134 (Rev 05/25/11) Y Page 2
Page 2/2
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Affidavit of Support Form - New Jersey PDF
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