Affidavit of Support Form Sample

Form I-134 02/19/14 Y Page 2
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.)
with7. I am employed as or engaged in the business of
(Name of Concern)(Type of Business)
at
(Zip Code)
(State)
(City)(Street Number and Name
I have on deposit in savings banks in the United States:
$
$
$
I have other personal property, the reasonable value of which is:
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)
8. The following persons are dependent upon me for support: (Check the box in the appropriate column to indicate whether the person named is
wholly or partially dependent upon you for support.)
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 of Person
I have life insurance in the sum of:
I own real estate valued at:
$
$
$
$
Date submitted
With a cash surrender value of:
do not intend to make specific contributions to the support of the person(s) named in item 3.
10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services on behalf of the following person(s). If none, state "None".
Date submittedRelationshipName of Person
11. I intend
(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 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 "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
(Street Number and Name)
-
-
, ,
,,
Page 2/2
Free Download

Affidavit of Support Form Sample PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 2032 Views | 58 Downloads
  •  
  •  
  •  
  •  
  •  
5 Page(s) | 3102 Views | 47 Downloads
  •  
  •  
  •  
  •  
  •  
4 Page(s) | 2128 Views | 1 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1334 Views | 3 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 1136 Views | 10 Downloads