Affidavit of Support Form - North Carolina

I have stocks and bonds with the following market value, as indicated on the attached list,
which I certify to be true and correct to the best of my knowledge and belief:
With mortgage(s) or other encumbrance(s) thereon amounting to: $
Which is located at:
(Zip Code)
(City) (State)(Street and Number)
8.
Name of Person
Wholly Dependent Partially Dependent Age Relationship to Me
9. I have previously submitted affidavit(s) of support for the following person(s). If none, state none.
Name
10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services (USCIS) on behalf of the
following person(s). If none, state none.
Date submitted
Relationship
Name
11. I
intend
do not intend to make specific contributions to the support of the person(s) named in item 3.
(If you check "intend," indicate the exact nature and duration of the contributions. 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 state whether it is to be given in a lump
sum, weekly or monthly, and for how long.
Oath or Affirmation of Sponsor.
I acknowledge that I have read Part lll of the Instructions, Sponsor and Alien Liability, and am aware of my responsibilities
as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.
Signature of sponsor
day ofSubscribed and sworn to (affirmed) before me this
at . My commission expires on
Title
If the affidavit is prepared by someone other than the sponsor, please complete the following: I declare that this document
was prepared by me at the request of the sponsor and is based on all information of which I have knowledge.
(Date)(Signature) (Address)
I have life insurance in the sum of:
I own real estate valued at:
$
$
$
$
The following persons are dependent upon me for support: (Place an "x" in the appropriate column to indicate
whether the person named is wholly or partially dependent upon you for support.)
Date submitted
,
Form I-134 (Rev. 02/28/07)YPage 2
I swear (affirm) that I know the contents of this affidavit signed by me and that the statements are true and correct.
Signature of Officer Administering Oath
With a cash surrender value of:
Page 4/4
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Affidavit of Support Form - North Carolina PDF

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