Sample Form for Affidavit of Support

Form I-134 Instructions 02/19/14 Y Page 3
We may request more information or evidence, or we may
request that you appear at a USCIS office for an interview.
We may also request that you submit the originals of any
copy. We will return these originals when they are no longer
required.
As an alternative to waiting in line for assistance at your local
USCIS office, you can now schedule an appointment through
our Internet-based system, InfoPass. To access the system,
visit our Web site. Use the InfoPass appointment scheduler
and follow the screen prompts to set up your appointment.
InfoPass generates an electronic appointment notice that
appears on the screen.
USCIS Forms and Information
To ensure you are using the latest version of this form, visit
the USCIS Web site at www.uscis.gov where you can obtain
the latest USCIS forms and immigration-related information.
If you do not have internet access, you may order USCIS
forms by calling our toll-free number at 1-800-870-3676.
You may also obtain forms and information by calling our
USCIS National Customer Service Center at
1-800-375-5283. For TDD (hearing impaired) call:
1-800-767-1833.
ROUTINE USES: The information you provide on this
benefit application may be shared with other federal, state,
local, and foreign government agencies and authorized
organizations in accordance with approved routine uses, as
described in the associated published system of records
notices [DHS-USCIS-007 - Benefits Information System
and DHS-USCIS-001 - Alien File (A-File) and Central
Index System (CIS), which can be found at www.dhs.gov/
privacy]. The information may also be made available, as
appropriate for law enforcement purposes or in
the interest of national security.
DISCLOSURE: The information you provide is voluntary.
However, failure to provide the requested information, and
any requested evidence, may delay a final decision or result in
denial of your benefit request.
USCIS Privacy Act Statement
AUTHORITIES: The information requested on this benefit
application, and the associated evidence, is collected pursuant
to Sections 1182(a)(4), 1183, 1184(a), and 1258 of the
Immigration and Nationality Act (INA), as amended INA §
101, et seq.
PURPOSE: The information you provide will be used
principally by USCIS, or by any consular officer to whom it
may be furnished, in the processing of Form I-131,
Application for Travel Document, to determine whether you
have adequate financial means to support the individual for
whom parole is requested on form I-131 and that this
individual will not become a public charge.
Any Form I-134 that is not signed will be rejected with a
notice that your Form I-134 is deficient. You may correct
the deficiency and resubmit Form I-134. Form I-134 is not
considered properly filed until accepted by USCIS.
Once your Form I-134 has been accepted, it will be checked
for completeness, including submission of the required initial
evidence.
Processing Information
Requests for more information or interview
If you knowingly and willfully make any false statement on
Form I-134, or conceal any material fact, or submit a false
document with Form I-134, we will deny the application for
immigration benefits that the alien for whom you are
submitting Form I-134 has filed, and may deny any other
immigration benefits.
Penalties
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
collection of information is estimated at 90 minutes per
response, including the time for reviewing instructions, and
completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing
this burden, to: U.S. Citizenship and Immigration Services,
Regulatory Coordination Division, Office of Policy and
Strategy, 20 Massachusetts Ave NW, Washington, DC
20529-2140; OMB No. 1615-0014. Do not mail your
completed Form I-134 to this address.
Paperwork Reduction Act
Initial processing
In addition, you will face severe penalties provided by law and
may be subject to criminal prosecution.
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