Affidavit of Support Form - North Carolina
OMB No. 1615-0014; Exp. 04-30-07
I-134, Affidavit of Support
(Answer all items. Type or print in black ink.)
1. I was born on
(City)
If you are not a native born U.S. citizen, answer the following as appropriate:
a. If a U.S.citizen through naturalization, give certificate of naturalization number
c. If U.S. citizenship was derived by some other method, attach a statement of explanation.
d. If a lawfully admitted permanent resident of the United States, give "A" number
2. I am
years of age and have resided in the United States since (date)
3. This affidavit is executed on behalf of the following person:
Gender
Age
(Middle Name)
Citizen of (Country) Relationship to Sponsor
Marital Status
Presently resides at (Street and Number) (Country)(City) (State)
Name of spouse and children accompanying or following to join person:
Child
Gender Age
Child Gender Age
Child Gender Age
Spouse Age
Child
Child Gender Age
4.
5.
6.
with
7. I am employed as or engaged in the business of
(Name of Concern)
(Type of Business)
at
(Zip Code)
(State)
(City)(Street and Number)
I derive an annual income of: (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.)
I have on deposit in savings banks in the United States:
$
Department of Homeland Security
U.S. Citizenship and Immigration Services
at
Being duly sworn depose and say:
This affidavit is made by me for the purpose of assuring the U.S. Government that the person(s) named in
item (3) will not become a public charge in the United States.
I am willing and able to receive, maintain and support the person(s) named in item 3. That I am ready and willing 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
United States, or to guarantee that the above named person(s) 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.
I understand this affidavit will be binding upon me for a period of three (3) years after entry of the person(s) named in
item (3) and that the information and documentation provided by me may be made available to the Secretary of Health and Human
Services and the Secretary of Agriculture, who may make it available to a public assistance agency.
$
$
Gender
Gender
Age
(Date-mm/dd/yyyy)
Form I-134 (Rev. 02/28/07) Y
(Country)
I have other personal property, the reasonable value of which is:
b. If a U.S. citizen through parent(s) or marriage, give citizenship certificate number
Name (Family Name) (First Name)
residing at
I,
(Street and Number)
(Name)
(Zip Code if in U.S.) (Country)(State)
(City)
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