Affidavit of Financial Support and Intent to Petition for Legal Custody of Public Law 97-359 Amerasian Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in black ink. USCIS Form I-361 Part 1. Information About You (Sponsor) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Date of Birth (mm/dd/yyyy) Mailing Address 9.a. In Care of Name 9.b. Street Number and Name 9.c. Apt. Ste. Flr. 3.a. City of Birth 9.d. City or Town 9.e. State 9.f. ZIP Code 3.b. Country of Birth 9.g. Province 9.h. Postal Code 9.i. Country 4. Alien Registration Number (A-Number) (if any) AU.S. Social Security Number (if any) USCIS ELIS Account Number (if any) 5. Information About Citizenship 10. 11. Are you a U.S. citizen? How did you acquire your U.S. citizenship? Birth Parents Naturalization Other Yes No 6. Physical Address 7.a. Street Number and Name 7.b. Apt. Ste. Flr. 12.a. If you acquired your U.S. citizenship through your parents, have you obtained a Certificate of Citizenship in your own name? Yes No If you answered "Yes," provide the following information about your Certificate of Citizenship: 7.c. City or Town 7.d. State 7.f. Province 7.e. ZIP Code 12.b. Name Under Which the Certificate of Citizenship Was Issued Family Name (Last Name) Given Name (First Name) Middle Name 7.g. Postal Code 7.h. Country 8. Are your physical address and mailing address the same? Yes No 12.c. Certificate of Citizenship Number If you answered "No" to Item Number 8., provide your mailing address in Item Numbers 9.a. - 9.i. 12.d. Date of Issuance (mm/dd/yyyy) 12.e. Place of Issuance Form I-361 09/11/15 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 8 Part 1. Information About You (Sponsor) (continued) If you acquired your U.S. citizenship through naturalization, provide the following information about your Certificate of Naturalization: 13.a. Name Under Which the Certificate of Naturalization Was Issued Family Name (Last Name) Given Name (First Name) Middle Name 13.b. Certificate of Naturalization Number 4. Country of Birth 5. A-Number (if any) AMarital Status Single (never married) Married Widowed Legally Separated Relationship to Sponsor 6. Divorced 7. Physical Address 8.a. Street Number and Name 8.b. Apt. Ste. Flr. 13.c. Date of Naturalization (mm/dd/yyyy) 8.c. City or Town 13.d. Place of Naturalization 8.d. State 14. If you acquired your U.S. citizenship through any other method please provide an explanation. If you need additional space to complete this section, use the space provided in Part 8. Additional Information. 8.f. Province 8.e. ZIP Code 8.g. Postal Code 8.h. Country Part 3. Other Information Employment Information 1. Name of Employer 2. 15. Provide the date you started residing in the United States (mm/dd/yyyy). Type of Business Employer Address Part 2. Information About Beneficiary This affidavit is executed on behalf of the following person: 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. 3. Date of Birth (mm/dd/yyyy) Gender Male Female 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.f. Province 3.e. ZIP Code 3.g. Postal Code 3.h. Country Form I-361 09/11/15 N Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Income Information 4.a. My annual income: 4.b. Are you self-employed? $ Yes No Address 2 11.a. Street Number and Name 11.b. Apt. Ste. Flr. If you answered "Yes," attach a copy of your last income tax return or report of commercial rating concern, which you certify as true and correct to the best of your knowledge. 5. Amount deposited in United States banks: $ 6. Value of my other personal property: $ 7. Market value of my stocks and bonds: $ NOTE: Attach a list of stocks and bonds which you certify as true and correct to the best of your knowledge. 8.a. Sum of my life insurance policies: $ 8.b. Cash surrender value of my life insurance policies: $ 11.c. City or Town 11.d. State 11.f. Province 11.g. Postal Code 11.h. Country 11.e. ZIP Code Dependents Information The following persons are dependent upon me for support. If you need additional space for your explanation, use the space provided in Part 8. Additional Information. 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name 12.d. Date of Birth (mm/dd/yyyy) 12.e. A-Number (if any) Real Estate Information 9.a. Value of my owned real estate: $ NOTE: If you own real estate, provide the physical addresses in Item Numbers 10.a. - 10.h. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 9.b. Amount of mortgages or other debts against my real estate: $ Address 1 10.a. Street Number and Name 10.b. Apt. Ste. Flr. A- 12.f. This person is: Wholly Dependent 12.g. Relationship Partially Dependent 13.a. Family Name (Last Name) 13.b. Given Name (First Name) 13.c. Middle Name 10.c. City or Town 10.d. State 10.f. Province 10.g. Postal Code 10.h. Country 10.e. ZIP Code 13.d. Date of Birth (mm/dd/yyyy) 13.e. A-Number (if any) A- 13.f. This person is: Wholly Dependent 13.g. Relationship Partially Dependent Form I-361 09/11/15 N Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Other Information (continued) 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name 14.d. Date of Birth (mm/dd/yyyy) 14.e. A-Number (if any) 17.e. Date of Filing (mm/dd/yyyy) 17.f. Relationship 18. Have you ever submitted or are you submitting visa petitions to USCIS for any other beneficiaries? Yes No A- 14.f. This person is: Wholly Dependent 14.g. Relationship Partially Dependent If you answered "Yes" to Item Number 18., provide the responses to Item Numbers 19.a. - 19.f. for each previous beneficiary. If you need to provide information for more than one beneficiary, use the space provided in Part 8. Additional Information. 19.a. A-Number (if any) A- 19.b. Family Name (Last Name) 19.c. Given Name (First Name) 19.d. Middle Name 19.e. Date of Filing (mm/dd/yyyy) 19.f. Relationship 15.a. Family Name (Last Name) 15.b. Given Name (First Name) 15.c. Middle Name 15.d. Date of Birth (mm/dd/yyyy) 15.e. A-Number (if any) A- 15.f. This person is: Wholly Dependent 15.g. Relationship Partially Dependent Part 4. Sponsor's Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-361 Instructions before completing this part. 16. Have you ever submitted