Sample Form for Affidavit of Support

Form I-134 Instructions 02/19/14 Y Page 1
Department of Homeland Security
U.S. Citizenship and Immigration Services
Instructions for Form I-134, Affidavit of Support
What Is the Purpose of This Form?
Section 212(a)(4) of the Immigration and Nationality Act (the
Act) bars the admission into the United States any alien who,
in the opinion of the U.S. Department of State officer
adjudicating a visa application, a Department of Homeland
Security officer, or an immigration judge adjudicating an
application for admission, is likely at any time to become a
public charge.
If you are sponsoring more than one alien, you must submit a
separate Form I-134 for each alien. Form I-134 must be
signed in your full name. (Note: Signing Form I-134 is under
penalty of perjury under U.S. law). For this reason, it is not
necessary to sign Form I-134 before a notary, nor to have your
signature notarized after you sign it.
OMB No. 1615-0014
; Expires 02/29/2016
Read these instructions carefully to properly complete this form. If you need more space to complete an answer, use a
separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of
paper and indicate the part and number of the item to which the answer refers.
Execution of Affidavit
For aliens seeking admission or adjustment as permanent
residents as immediate relatives, family-based immigrants,
and certain employment based immigrants, as specified in
sections 212(a)(4)(C) and 213A of the Act and 8 CFR Part
213a, the petitioning relative must file Form I-864.
Form I-134 may be used in any case in which you are
inadmissible on public charge grounds, but in which you are
not required to have Form I-864 filed on his or her behalf.
Section 213 of the Act (not section 213A) permits the
admission of an alien who is inadmissible on public charge
grounds, in the discretion of the Secretary of Homeland
Security (or, for immigration judge cases, the discretion of the
Attorney General) upon the posting of a bond or other
undertaking (method). Form I-134, is the “undertaking
prescribed in section 213 of the Act.
2. If extra space is needed to complete any item, attach a
continuation sheet, indicate the item number, and date and
sign each sheet.
Do not use Form I-134 if the alien whom you are sponsoring
is required to have Form I-864 instead.
A. Statement from an officer of the bank or other financial
institutions with deposits, identifying the following details
regarding the account:
As the sponsor, you must show you have sufficient income
or financial resources to assure that the alien you are
sponsoring will not become a public charge while in the
United States.
Evidence should consist of copies of any of the
documents listed below that apply to your situation.
Failure to provide evidence of sufficient income or
financial resources may result in the denial of the alien's
application for a visa or his or her removal from the United
Submit in duplicate evidence of income and resources,
as appropriate:
1. Date account opened;
Supporting Evidence
2. Total amount deposited for the past year; and
3. Present balance.
B. Statement(s) from your employer on business stationery
1. Date and nature of employment;
2. Salary paid; and
3. Whether the position is temporary or permanent.
Fill Out Form I-134
General Instructions
1. Type or print legibly in black ink.
1. Copy of last income tax return filed; or
C. If self-employed:
2. Report of commercial rating concern.
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