Form I-134 02/13/19 Page 1 of 8Affidavit of Support Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-134 OMB No. 1615-0014 Expires 02/28/2021 START HERE - Type or print in black ink. Part 1. Information About You (the Sponsor)1.a.Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Your Full Name Other Names UsedList all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 7. Additional Information.2.a.Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Sponsor's Mailing Address 3.d.3.e.3.b.3.c.3.h.3.i.3.g.City or TownState3.f. ZIP CodePostal CodeProvinceCountryStreet Number and Name Apt. Ste. Flr.In Care Of Name 3.a.4.Are your mailing address and physical address the same? No YesIf you answered "No" to Item Number 4., provide your physical address in Item Numbers 5.a. - 5.h. Sponsor's Physical Address5.b.5.c.5.a.5.f.5.g.5.d.5.h.City or TownState5.e.ZIP CodePostal CodeProvinceCountryStreet Number and Name Ste. Flr. Apt. Other Information6.Date of Birth (mm/dd/yyyy) 7.a.Town or City of Birth U.S. Social Security Number (if any)9. USCIS Online Account Number (if any)10. A- Alien Registration Number (A-Number) (if any)8.7.b.Country of Birth If you are not a U.S. citizen based on your birth in the United States, or a non-citizen U.S. national based on your birth in American Samoa (including Swains Island), answer the following as appropriate: Citizenship or Residency or Status11.a. I am a U.S. citizen through parent(s) or marriage. My Certificate of Citizenship number is 11.b. I am a U.S. citizen through naturalization. My Certificate of Naturalization number is (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Form I-134 02/13/19 Page 2 of 8 Part 1. Information About You (the Sponsor)(continued)I derived my U.S. citizenship by another method. (Provide an explain in Part 7. Additional Information.) 11.c.11.d.I am a lawfully admitted nonimmigrant. My Form I-94, Arrival-Departure Record Number is 11.e. I am a lawful permanent resident of the United States. My A-Number is12. Part 2. Information About the BeneficiaryI am States since (Date) (mm/dd/yyyy)years of age and have resided in the United 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.Date of Birth (mm/dd/yyyy) MaleFemale3.Gender A- A-Number (if any)4.5.Country of Citizenship or Nationality 8.c.8.d.8.a.8.b.8.g.8.h.8.f.City or TownState8.e. ZIP CodePostal CodeProvinceCountryStreet Number and Name Ste. Flr. Apt. A- Marital Status6. Married Legally Separated Widowed Single or Single, Never Married Divorced Other Marriage AnnulledRelationship to Sponsor 7. Beneficiary's Physical Address Beneficiary's Spouse (accompanying or following to join beneficiary)9.a.Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name 10.Date of Birth (mm/dd/yyyy) Gender14.FemaleMale MaleFemale11.Gender Beneficiary's ChildrenChild 112.a.Family Name (Last Name) 12.b.Given Name (First Name) 12.c.Middle Name 13.Date of Birth (mm/dd/yyyy) Child 215.a.Family Name (Last Name) 15.b.Given Name (First Name) 15.c.Middle Name 16.Date of Birth (mm/dd/yyyy) Gender17.FemaleMale If you need additional space to complete this section, use the space provided in Part 7. Additional Information. American LegalNet, Inc. www.FormsWorkFlow.com Form I-134 02/13/19 Page 3 of 8 Part 3. Other Information About the Sponsor Employment Information1.b.I am currently: Employed as a/an1.a. 1.a.1.Name of Employer (if applicable) Self employed as a/an Current Employer Address (if employed)2.c.2.d.2.a.2.b.2.g.2.h.2.f.City or TownState2.e. ZIP CodePostal CodeProvinceCountryStreet Number and Name Ste. Flr. Apt. Income and Asset Information3.My annual income is$ (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.)4.$5.Value of my other personal property$ Balance of all my savings and checking accounts in United States-based financial institutions6.Market value of my stocks and bonds$ I have listed my stocks and bonds in Part 7. Additional Information (or attached a list of them), which I certify to be true and correct to the best of my knowledge and belief.7.a.$ 7.b.With a cash surrender value of$ I have life insurance in the sum of Real Estate Information8.a.$ 8.b.I have mortgages or other debts amounting to$ I own real estate valued atMy real estate is located at:9.c.9.d.9.a.9.b.City or TownState9.e. ZIP CodeStreet Number and Name Ste. Flr. Apt. Dependents' InformationThe following persons are dependent upon me for support. If you need extra space to complete this section, use the space provided in Part 7. Additional Information.10.a.Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11.Relationship to Me: Date of Birth (mm/dd/yyyy) 13.Wholly Dependent On Me For Support Partially Dependent On Me For Support 12.This person is:14.a.Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name 15.Relationship to Me: 16.Date of Birth (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com Form I-134 02/13/19 Page 4 of 8 Part 3. Other Information About the Sponsor (continued)17.Wholly Dependent On Me For Support Partially Dependent On Me For Support 18.a.Family Name (Last Name) 18.b. Given Name (First Name) 18.c. Middle Name This person is:19.Date of Birth (mm/dd/yyyy) 20.Relationship to Me: 21.Wholly Dependent On Me For Support This person is: Partially Dependent On Me For Support I have previously submitted affidavit(s) of support for the following person(s). (If none, write "None" in the space for name below.)22.a.Family Name (Last Name) 22.b.Given Name (First Name) 22.c.Middle Name Date Submitted (mm/dd/yyyy) 23. 24.a.Family Name (Last Name) 24.b.Given Name (First Name) 24.c.Middle Name Date Submitted (mm/dd/yyyy) 25. 33.Date of Filing (mm/dd/yyyy)32. Date of Birth (mm/dd/yyyy)31.Relationship to Me: Middle Name30.c. Given Name (First Name) 30.b. Family Name (Last Name) 30.a.Date of Birth (mm/dd/yyyy) 28.Date of Filing (mm/dd/yyyy)29. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services on behalf of the following persons. (If none, write 223None224 in the space for name below.)26.a.Family Name (Last Name) 26.b.Given Name (First Name) 26.c.Middle Name Relationship to Me:27. 37.38.IintendDate of Filing (mm/dd/yyyy)36. Date of Birth (mm/dd/yyyy)35.Relationship to Me: Middle Name34.c. Given Name (First Name) 34.b. Family Name (Last Name) 34.a. contributions to the support of the person(s) named in Part 2.(If you select "intend," indicate the exact nature and duration of the contributions you intend to make in Part 7. Additional Information. 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.)do not intend to make specific American LegalNet, Inc. www.FormsWorkFlow.com Form I-134 02/13/19 Page 5 of 8 Part 4. Sponsor's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-134 Instructions before completing this part. NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.1.a.I can read and understand English, and I have read and understand every question and instruction on this affidavit and my answer to every question. Sponsor's StatementThe interpreter named in Part 5. read to me every question and instruction on this affidavit and my answer to every question in 1.b. a language in which I am fluent and I understood everything., At my request, the preparer named in Part 6., 2. ,5.Sponsor's Email Address (if any) Sponsor's Mobile Telephone Number (if any)4. Sponsor's Daytime Telephone Number3. Sponsor's Contact Informationprepared this affidavit for