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OMB No. 1615-0014; Expires 02/29/2016

Department of Homeland Security
U.S. Citizenship and Immigration Services

Form I-134, Affidavit of Support
(Answer all items. Type or print in black ink.)

I,

,

, residing at
(Name)

(Street Number and Name)
-

,
(State)

(City)

,

(Zip Code if in U.S.)

(Country)

certify under penalty of perjury under U.S. law, that:
1. I was born on

,

in
(Date [mm/dd/yyyy])

(City)

,
(State)

(Country)

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:
a. If a U.S.citizen through naturalization, give Certificate of Naturalization number
b. If a U.S. citizen through parent(s) or marriage, give Certificate of Citizenship number
c. If U.S. citizenship was derived by some other method, attach a statement of explanation.
d. If a Lawful Permanent Resident of the United States, give A-Number
e. If a lawfully