Form I-134, Declaration of Financial Support Instructions
This form contains 320 fields organized into 50 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Part 8. Additional Information. 3. D. Enter Additional Information | Text |
Provide any additional information that is relevant to your declaration of financial support.
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| Part 8. Additional Information. 3. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 8. Additional Information. 3. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 8. Additional Information. 3. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 8. Additional Information. 4. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 8. Additional Information. 4. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 8. Additional Information. 4. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 8. Additional Information. If you need extra space to provide any additional information within this declaration, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this declaration or attach a separate sheet of paper. Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. No Entry 1. Middle Name (pre-populated from page 1) | Text |
Provide any additional information related to your declaration. If you need more space, you can make copies of this page or attach a separate sheet. Ensure to type or print your name and A-Number at the top of each sheet, and indicate the Page Number, Part Number, and Item Number to which your answer refers. Sign and date each sheet.
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| Part 8. Additional Information. 5. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 8. Additional Information. 5. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 8. Additional Information. 5. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 8. Additional Information. 6. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 8. Additional Information. 6. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 8. Additional Information. 6. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 8. Additional Information. 4. D. Enter Additional Information | Text |
Provide any additional information related to your declaration for the specified part and item number.
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| Part 8. Additional Information. 5. D. Enter Additional Information | Text |
Provide any additional information related to your declaration for the specified part and item number.
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| Part 8. Additional Information. 6. D. Enter Additional Information | Text |
Provide any additional information related to your declaration for the specified part and item number.
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| Address Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 4. Is your current mailing address the same as your current physical address? Check this box for Yes | CheckBox |
Check this box if your current mailing address is the same as your current physical address.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 4. Is your current mailing address the same as your current physical address? Check this box for No. Note: If you answered No to Item Number 4., provide your current physical address in Item Numbers 5 | CheckBox |
Check this box if your current mailing address is not the same as your current physical address. If you check this box, provide your current physical address in Item Numbers 5.
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| Applicant's Signature | ||
| Signature of Applicant. This form can not be signed electronically. The name of the applicant can not be typewritten into this space. If the applicant is a minor child, the parent must sign the child's name in this space. This form will be rejected without a signature in this space | Text |
Provide the signature of the applicant. This form cannot be signed electronically, and the name cannot be typewritten. If the applicant is a minor, the parent must sign the child's name. The form will be rejected without a signature.
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| Date of Signature. Enter the 2 digit month, 2 digit day and 4 digit year | Text |
Enter the date of the signature in the format MM/DD/YYYY.
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| Basis for Filing | ||
| Part 1. Basis for Filing. 1. I am filing this form on behalf of: Check this box for Another individual who is the beneficiary | CheckBox |
Check this box if you are filing this form on behalf of another individual who is the beneficiary.
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| Part 1. Basis for Filing. 1. I am filing this form on behalf of: Check this box for Myself as the beneficiary | CheckBox |
Check this box if you are filing this form on behalf of yourself as the beneficiary.
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| Beneficiary Certification | ||
| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I- 1 34 on his or her own behalf). If you are the beneficiary and are filing Form I- 1 34 on your own behalf, complete and sign Part 4. If you are not the beneficiary who is filing Form I- 1 34 on your own behalf, type or print N / A in Item Numbers 1. to 6. NOTE: Read the Penalties section of the Form I- 1 34 Instructions before completing this section. 1. A. I as the beneficiary, certify the following: Check this box for I can read and understand English, and I have read and understand every question and instruction on this declaration and my answer to every question | CheckBox |
Check this box if you, as the beneficiary, can read and understand English and have read and understood every question and instruction on this declaration.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I- 1 34 on his or her own behalf). 1. B. I as the beneficiary, certify the following: Check this box for The interpreter named in Part 6. read to me every question and instruction on this declaration and my answer to every question in a language in which I am fluent and I understand | CheckBox |
Check this box if an interpreter read every question and instruction on this declaration to you in a language in which you are fluent and you understand.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I- 1 34 on his or her own behalf). 2. Check this box for At my request, the preparer named in Part 7. prepared this declaration for me based only upon information I provided or authorized | CheckBox |
Check this box if the preparer named in Part 7 prepared this declaration for you based only on information you provided or authorized.
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| Beneficiary Contact Information | ||
| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I-134 on his or her own behalf). Beneficiary's Contact Information. 5. Enter the Beneficiary's Email Address (if any) | Text |
Enter the beneficiary's email address, if any.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I-134 on his or her own behalf). Beneficiary's Contact Information. 4. Enter the Beneficiary's Mobile Telephone Number (if any) | Text |
Enter the beneficiary's mobile telephone number, if any.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I-134 on his or her own behalf). Beneficiary's Contact Information. 3. Enter the Beneficiary's Daytime Telephone Number | Text |
Enter the beneficiary's daytime telephone number.
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| Beneficiary Information | ||
| Part 2. Information about the Beneficiary. 1. Beneficiary's Current Legal Name (Do not provide a nickname). Enter Middle Name | Text |
Enter the middle name of the beneficiary's current legal name. Do not provide a nickname.
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| Part 2. Information about the Beneficiary. 1. Beneficiary's Current Legal Name (Do not provide a nickname). Enter Given Name (Last Name) | Text |
Enter the given name (first name) of the beneficiary's current legal name. Do not provide a nickname.
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| Part 2. Information about the Beneficiary. Complete Part 2. regardless of whether you are filing this form on behalf of yourself as the beneficiary or on behalf of another individual who is the beneficiary. 1. Beneficiary's Current Legal Name (Do not provide a nickname). Enter Family Name (Last Name) | Text |
Enter the family name (last name) of the beneficiary's current legal name. Do not provide a nickname.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Row 2. Enter Middle Name | Text |
Enter the middle name of any other names the beneficiary has used.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Row 2. Enter Given Name (Last Name) | Text |
Enter the given name (first name) of any other names the beneficiary has used.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Provide all other names the beneficiary has ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Row 2. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of any other names the beneficiary has used, including aliases, maiden name, and nicknames. If you need extra space, use Part 8. Additional Information.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Row 1. Enter Middle Name | Text |
Enter the middle name of any other names the beneficiary has used.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Row 1. Enter Given Name (Last Name) | Text |
Enter the given name (first name) of any other names the beneficiary has used.
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| Part 2. Information about the Beneficiary. 2. Other Names Used. Provide all other names the beneficiary has ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Row 1. Enter Family Name (Last Name) | Text |
Provide all other names the beneficiary has ever used, including aliases, maiden name, and nicknames. Enter the family name (last name) here.
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| Part 2. Information about the Beneficiary. 3. Date of Birth. Enter date as 2-digit month, 2-digit day, and 4-digit year | Text |
Enter the beneficiary's date of birth in the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. 4. Gender. Check this box for Female | CheckBox |
Check this box if the beneficiary's gender is female.
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| Part 2. Information about the Beneficiary. 4. Gender. Check this box for Male | CheckBox |
Check this box if the beneficiary's gender is male.
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| Part 2. Information about the Beneficiary. 5. Enter 9 digit Alien Registration Number (A Number)(if any) | Text |
Enter the beneficiary's 9-digit Alien Registration Number (A Number), if any.
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| Part 2. Information about the Beneficiary. 7. Enter Country of Citizenship or Nationality | Text |
Enter the beneficiary's country of citizenship or nationality.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Divorced | CheckBox |
Check this box if the beneficiary's marital status is divorced.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Single, Never Married | CheckBox |
Check this box if the beneficiary's marital status is single and never married.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Widowed | CheckBox |
Check this box if the beneficiary's marital status is widowed.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Married | CheckBox |
Check this box if the beneficiary's marital status is married.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Legally Separated | CheckBox |
Check this box if the beneficiary's marital status is legally separated.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I-134 on his or her own behalf). Beneficiary's Signature. 6. Enter the Beneficiary Signature. This field cannot be signed electronically | Text |
Enter the beneficiary's signature. Note: This field cannot be signed electronically.
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| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I-134 on his or her own behalf). Beneficiary's Signature. 6. Enter the Date of Signature. Enter the Date Submitted. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of the beneficiary's signature. Use the format MM/DD/YYYY.
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| Beneficiary Mailing Address | ||
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Enter the In Care of Name (if any) | Text |
Enter the 'In Care of' name for the beneficiary's mailing address, if applicable. Maximum length is 34 characters.
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| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Enter the Street Number and Name | Text |
Enter the street number and name for the beneficiary's mailing address. Maximum length is 34 characters.
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| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Check this box for Apartment | CheckBox |
Check this box if the beneficiary's mailing address includes an apartment.
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| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Check this box for Suite | CheckBox |
Check this box if the beneficiary's mailing address includes a suite.
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| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Check this box for Floor | CheckBox |
Check this box if the beneficiary's mailing address includes a floor.
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| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number for the beneficiary's mailing address. Maximum length is 6 characters.
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| Beneficiary Marital Status | ||
| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Other | CheckBox |
Check this box if the beneficiary's marital status is 'Other'.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Enter an explanation for Other marital Status | Text |
Enter an explanation for the beneficiary's marital status if 'Other' was selected.
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| Part 2. Information about the Beneficiary. 8. Marital Status. Check this box for Marriage Anulled | CheckBox |
Check this box if the beneficiary's marriage was annulled.
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| Beneficiary Place of Birth | ||
| Part 2. Information about the Beneficiary. 6. Place of Birth. Enter Country | Text |
Enter the country where the beneficiary was born.
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| Part 2. Information about the Beneficiary. 6. Place of Birth. Enter State or Province | Text |
Enter the state or province where the beneficiary was born. Maximum length is 20 characters.
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| Part 2. Information about the Beneficiary. 6. Place of Birth. Enter City or Town | Text |
Enter the city or town where the beneficiary was born. Maximum length is 28 characters.
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| Beneficiary's Address Confirmation | ||
| Part 2. Information about the Beneficiary. 10. Are the beneficiary's mailing address and physical address the same? Check this box for Yes | CheckBox |
Check this box if the beneficiary's mailing address and physical address are the same.
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| Part 2. Information about the Beneficiary. 10. Are the beneficiary's mailing address and physical address the same? Check this box for No. Note: If you answered No to Item Number 10. provide your physical address in Item Number 11 | CheckBox |
Check this box if the beneficiary's mailing address and physical address are not the same. If you check this box, provide the physical address in the next section.
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| Beneficiary's Anticipated Length of Stay | ||
| Part 2. Information about the Beneficiary. Beneficiary's Anticipated Length of Stay. 12. Beneficiary's Anticipated Period of Stay in the United States. Enter the Date From. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the start date of the beneficiary's anticipated period of stay in the United States. Use the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. Beneficiary's Anticipated Length of Stay. 12. Beneficiary's Anticipated Period of Stay in the United States. Check this box if there is an Anticipated end date | CheckBox |
Check this box if there is an anticipated end date for the beneficiary's stay in the United States.
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| Part 2. Information about the Beneficiary. Beneficiary's Anticipated Length of Stay. 12. Beneficiary's Anticipated Period of Stay in the United States. Enter the End Date. Enter the Anticipated end date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the end date of the beneficiary's anticipated period of stay in the United States. Use the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. Beneficiary's Anticipated Length of Stay. 12. Beneficiary's Anticipated Period of Stay in the United States. Enter the End Date. Check this box for No End Date Anticipated | CheckBox |
Check this box if there is no anticipated end date for the beneficiary's stay in the United States.
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| Beneficiary's Assets | ||
| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Enter the Total Assets (in U. S. Dollars). This field is calculated | Text |
Enter the total value of the beneficiary's assets in U.S. dollars. This field is calculated automatically.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 1. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list for the first row. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property, Savings, Retirement or Educational Account, Checking, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 2. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list for the second row. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property, Savings, Retirement or Educational Account, Checking, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 3. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list for the third row. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property, Savings, Retirement or Educational Account, Checking, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 4. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list that corresponds to the beneficiary's asset in row 4.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 5. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list that corresponds to the beneficiary's asset in row 5.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 6. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list that corresponds to the beneficiary's asset in row 6.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 7. Select the Type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list that corresponds to the beneficiary's asset in row 7.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Enter the Current Cash Value (in U. S. Dollars) | Text |
Enter the current cash value of the beneficiary's assets in U.S. dollars.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 1. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's asset in row 1 in U.S. dollars.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 2. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's asset in row 2 in U.S. dollars.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 3. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's asset in row 3 in U.S. dollars.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 4. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's assets in U.S. dollars for Row 4.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 5. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's assets in U.S. dollars for Row 5.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 6. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's assets in U.S. dollars for Row 6.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. Row 7. Enter the Amount (Cash Value. In U. S. Dollars) | Text |
Enter the cash value amount of the beneficiary's assets in U.S. dollars for Row 7.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 1. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for Row 1. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 2. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for Row 2. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 3. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for Row 3. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 4. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for Row 4. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 5. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for the beneficiary's assets in Row 5. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 6. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for the beneficiary's assets in Row 6. Attach evidence showing that the beneficiary has these assets.
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| Part 2. Information about the Beneficiary. Beneficiary's Assets. 18. In the table below, provide the amounts of assets available to the beneficiary for the expected period of his or her stay (excluding assets from any individuals named in Part 3.). Attach evidence showing that the beneficiary has these assets. Row 7. Enter the Full Name of Asset Holder (First, Middle, Last) | Text |
Enter the full name (First, Middle, Last) of the asset holder for the beneficiary's assets in Row 7. Attach evidence showing that the beneficiary has these assets.
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| Beneficiary's Financial Information | ||
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Beneficiary's Income. 13. Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about assets that are not based on employment should be added in Item Number 16. and not in Item Number 13. Row 1. Individual's Full Name. (First, Middle, Last) (do not include any individuals named in Part 3.) | Text |
Provide the full name (first, middle, last) of the individual whose income and assets are being reported. Do not include any individuals named in Part 3.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Beneficiary's Income. 13. Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about assets that are not based on employment should be added in Item Number 16. and not in Item Number 13. Row 2. Individual's Full Name. (First, Middle, Last) (do not include any individuals named in Part 3.) | Text |
Provide the full name (First, Middle, Last) of the second individual financially supported by the beneficiary. Do not include any individuals named in Part 3.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Beneficiary's Income. 13. Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about assets that are not based on employment should be added in Item Number 16. and not in Item Number 13. Row 3. Individual's Full Name. (First, Middle, Last) (do not include any individuals named in Part 3.) | Text |
Provide the full name (First, Middle, Last) of the third individual financially supported by the beneficiary. Do not include any individuals named in Part 3.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Beneficiary's Income. 13. Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about assets that are not based on employment should be added in Item Number 16. and not in Item Number 13. Row 4. Individual's Full Name. (First, Middle, Last) (do not include any individuals named in Part 3.) | Text |
Provide the full name (First, Middle, Last) of the fourth individual financially supported by the beneficiary. Do not include any individuals named in Part 3.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Beneficiary's Income. 13. Provide all of the information requested in the table below about the beneficiary, all of the beneficiary's dependents, and any other individuals the beneficiary financially supports (do not include any individuals named in Part 3.). Information about assets that are not based on employment should be added in Item Number 16. and not in Item Number 13. Row 5. Individual's Full Name. (First, Middle, Last) (do not include any individuals named in Part 3.) | Text |
Provide the full name (First, Middle, Last) of the fifth individual financially supported by the beneficiary. Do not include any individuals named in Part 3.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 1. Enter the Individual's Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of the first individual financially supported by the beneficiary. Use the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 3. Enter the Individual's Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the beneficiary's date of birth in the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 5. Enter the Individual's Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the beneficiary's date of birth in the format MM/DD/YYYY.
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| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 5. Enter the Relationship to the Beneficiary. (Type or print Self if you are filing for yourself as the beneficiary or Beneficiary if someone is agreeing to support you in Part 3.) | Text |
Enter the relationship to the beneficiary. Type 'Self' if you are filing for yourself as the beneficiary or 'Beneficiary' if someone is agreeing to support you in Part 3.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 5. Enter Income contribution to the beneficiary annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If none, type or print $0.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 4. Enter Income contribution to the beneficiary annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If none, type or print $0.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 4. Enter the Relationship to the Beneficiary. (Type or print Self if you are filing for yourself as the beneficiary or Beneficiary if someone is agreeing to support you in Part 3.)1. Information About You (Person Requesting Family Unity Benefits). 2. A. Enter Family Name (Last Name) | Text |
Enter the relationship to the beneficiary. Type 'Self' if you are filing for yourself as the beneficiary or 'Beneficiary' if someone is agreeing to support you in Part 3.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 4. Enter the Individual's Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the beneficiary's date of birth in the format MM/DD/YYYY.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 3. Enter the Relationship to the Beneficiary. (Type or print Self if you are filing for yourself as the beneficiary or Beneficiary if someone is agreeing to support you in Part 3.) | Text |
Enter the relationship to the beneficiary. Type 'Self' if you are filing for yourself as the beneficiary or 'Beneficiary' if someone is agreeing to support you in Part 3.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 3. Enter Income contribution to the beneficiary annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If there is no contribution, type or print $0.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 2. Enter Income contribution to the beneficiary annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If there is no contribution, type or print $0.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 2. Enter the Relationship to the Beneficiary. (Type or print Self if you are filing for yourself as the beneficiary or Beneficiary if someone is agreeing to support you in Part 3.) | Text |
Enter the relationship to the beneficiary. Type or print 'Self' if you are filing for yourself as the beneficiary or 'Beneficiary' if someone is agreeing to support you in Part 3.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 2. Enter the Individual's Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the individual's date of birth in the format MM/DD/YYYY.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 1. Enter the Relationship to the Beneficiary. (Type or print Self if you are filing for yourself as the beneficiary or Beneficiary if someone is agreeing to support you in Part 3.) | Text |
Enter the relationship to the beneficiary. Type or print 'Self' if you are filing for yourself as the beneficiary or 'Beneficiary' if someone is agreeing to support you in Part 3.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Row 1. Enter Income contribution to the beneficiary annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If there is no contribution, type or print $0.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Enter the Total Number of Dependents | Text |
Enter the total number of dependents.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 13. Enter the Total Income for all Individuals. This field is calculated | Text |
Enter the total income for all individuals. This field is calculated.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 14. Does any of the beneficiary's total income (including income from dependents and other individuals who contribute to the beneficiary's income, excluding any individuals named in Part 3.) come from an illegal activity or source (such as proceeds from illegal gambling or illegal drug sales)? Check this box for No | CheckBox |
Indicate whether any part of the beneficiary's total income comes from illegal activities or sources, such as proceeds from illegal gambling or drug sales. Check this box if the answer is No.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 14. Does any of the beneficiary's total income (including income from dependents and other individuals who contribute to the beneficiary's income, excluding any individuals named in Part 3.) come from an illegal activity or source (such as proceeds from illegal gambling or illegal drug sales)? Check this box for Yes | CheckBox |
Indicate whether any part of the beneficiary's total income comes from illegal activities or sources, such as proceeds from illegal gambling or drug sales. Check this box if the answer is Yes.
|
| Part 2. Information about the Beneficiary. Beneficiary's Financial Information. Provide information about the beneficiary's income and assets. Beneficiary's Income. 15. If you answered Yes to Item Number 14., Enter the amount of the beneficiary's total income comes from an illegal activity or source | Text |
If you answered Yes to the previous question about illegal income sources, enter the amount of the beneficiary's total income that comes from these illegal activities or sources.
|
| Beneficiary's Information | ||
| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I- 1 34 on his or her own behalf). 1. B. Enter the language of fluency | Text |
Enter the language of fluency for the beneficiary if they are filing Form I-134 on their own behalf.
|
| Beneficiary's Mailing Address | ||
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. Enter the City or Town | Text |
Enter the city or town of the beneficiary's mailing address.
|
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. For U. S. Address. select the State from the list of States | ComboBox |
Select the state from the list for the beneficiary's U.S. mailing address.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
|
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit ZIP code for the beneficiary's U.S. mailing address.
|
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. For International Address. Enter the Province | Text |
Enter the province for the beneficiary's international mailing address.
|
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. For International Address. Enter the Postal Code | Text |
Enter the postal code for the beneficiary's international mailing address.
|
| Part 2. Information about the Beneficiary. 9. Beneficiary's Mailing Address. For International Address. Enter the Country | Text |
Enter the country for the beneficiary's international mailing address.
|
| Beneficiary's Physical Address | ||
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Enter the In Care of Name | Text |
Enter the name of the person in care of the beneficiary's physical address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary’s Physical Address. Enter the Street Number and Name (Do not provide a PO Box in this space unless it is your ONLY address.) | Text |
Enter the street number and name of the beneficiary's physical address. Do not provide a PO Box unless it is the only address available.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Check this box for Apartment | CheckBox |
Check this box if the beneficiary's physical address includes an apartment.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Check this box for Suite | CheckBox |
Check this box if the beneficiary's physical address includes a suite.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Check this box for Floor | CheckBox |
Check this box if the beneficiary's physical address includes a floor.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number of the beneficiary's physical address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. Enter the City or Town | Text |
Enter the city or town of the beneficiary's physical address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. For International Address. Enter the Province | Text |
Enter the province for the beneficiary's international address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. For U. S. Address. select the State from the list of States | ComboBox |
Select the state from the list for the beneficiary's U.S. address.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit zip code for the beneficiary's U.S. address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. For International Address. Enter the Postal Code | Text |
Enter the postal code for the beneficiary's physical address if it is an international address.
|
| Part 2. Information about the Beneficiary. 11. Beneficiary's Physical Address. For International Address. Enter the Country | Text |
Enter the country for the beneficiary's physical address if it is an international address.
|
| Employment Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 11. Employment Status. Check this box for Employed (full-time, part-time, seasonal, self-employed). Note: If you indicated that you are employed in Item Number 11., provide the information requested in Item Numbers 12. and 13. If you selected a different option in Item Number 11., type or print N / A in Item Numbers 12. - 13 | CheckBox |
Check this box if you are employed (full-time, part-time, seasonal, or self-employed). If you select this option, you will need to provide additional employment information in the following fields.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 11. Employment Status. Check this box for Unemployed or Not Employed | CheckBox |
Check this box if you are unemployed or not employed.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 11. Employment Status. Check this box for Retired | CheckBox |
Check this box if you are retired.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 11. Employment Status. Check this box for Other | CheckBox |
Check this box if your employment status is not listed and provide an explanation in the following field.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 11. Employment Status. Enter Explanation for Other Employment status | Text |
Enter an explanation for your employment status if you selected 'Other' in the previous field.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 12. A. Check this box for I am currently employed with an employer | CheckBox |
Check this box if you are currently employed with an employer.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 12. A. Enter the work title of your current employment | Text |
Enter your current job title if you are employed with an employer. Maximum length: 34 characters.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 12. A. Enter the Name of your Employer | Text |
Enter the name of your current employer. Maximum length: 34 characters.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 12. B. Check this box if you are currently self-employed | CheckBox |
Check this box if you are currently self-employed.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 12. A. Enter the work title of your current self-employment | Text |
Enter your current job title if you are self-employed. Maximum length: 34 characters.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. For International Address. Enter the Province | Text |
Enter the province of the current employer's address if it is an international address.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. For International Address. Enter the Postal Code | Text |
Enter the postal code of the current employer's address if it is an international address.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. For International Address. Enter the Country | Text |
Enter the country of the current employer's address if it is an international address.
|
| Financial Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Income. 14. Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you financially support (do not include any individuals named in Part 2.). Information about assets that are not based on employment should be added in Item Number 17. and not in Item Number 14. Row 1. Enter Full Name (First, Middle, Last) (do not include any individuals named in Part 2.) | Text |
Provide the full name (first, middle, last) of yourself, all of your dependents, and any other individuals you financially support. Do not include any individuals named in Part 2.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 1. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth for the individual listed in the income section. Use the format MM/DD/YYYY.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 1. Enter Relationship to the Individual Agreeing to Financially Support (Type or print Self for Individual Agreeing to Financially Support the Beneficiary) | Text |
Enter the relationship to the individual agreeing to financially support the beneficiary. Type or print 'Self' if you are the individual agreeing to financially support the beneficiary.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 1. Enter Income Contribution to the Beneficiary Annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If there is no contribution, type or print $0.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 4. Enter Income Contribution to the Beneficiary Annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary by the individual agreeing to financially support. If there is no contribution, type or print $0.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 3. Enter Income Contribution to the Beneficiary Annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary by the individual agreeing to financially support. If there is no contribution, type or print $0.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 5. Enter Income Contribution to the Beneficiary Annually (if none, type or print $0) | Text |
Enter the annual income contribution to the beneficiary. If there is no contribution, type or print '$0'.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. 14. Enter the Total Number of Dependents | Text |
Enter the total number of dependents the individual agreeing to financially support has.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. 14. Enter the Total Income. This filed is calculated | Text |
Enter the total income of the individual agreeing to financially support the beneficiary. This field is calculated.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. 15. Does any of the income listed above come from an illegal activity or source (such as proceeds from illegal gambling or illegal drug sales)? Check this box for Yes | CheckBox |
Check this box if any of the income listed comes from an illegal activity or source (such as proceeds from illegal gambling or illegal drug sales).
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. 15. Does any of the income listed above come from an illegal activity or source (such as proceeds from illegal gambling or illegal drug sales)? Check this box for No | CheckBox |
Check this box if none of the income listed comes from an illegal activity or source.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. 16. If you answered Yes to Item Number 15., Enter the amount of income that comes from an illegal activity. (Type or print N / A if you answered No to Item Number 15.) | Text |
If you answered 'Yes' to the previous question about illegal income, enter the amount of income that comes from an illegal activity. If you answered 'No', type or print 'N/A'.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 1. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder (you or your household member) for the assets available to you. Attach evidence showing you have these assets.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 1. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. This could include real estate holdings, stocks, bonds, certificates of deposit, personal property, savings, retirement or educational accounts, checking accounts, or annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 1. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. dollars. Ensure the amount is accurate and corresponds to the asset type selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 2. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder, which could be you or a member of your household. This name should match the documentation you will attach as evidence.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 2. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. This could include real estate holdings, stocks, bonds, certificates of deposit, personal property, savings, retirement or educational accounts, checking accounts, or annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 2. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. dollars. Ensure the amount is accurate and corresponds to the asset type selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 3. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder, which could be you or a member of your household. This name should match the documentation you will attach as evidence.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 3. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. This could include real estate holdings, stocks, bonds, certificates of deposit, personal property, savings, retirement or educational accounts, checking accounts, or annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 3. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. dollars. Ensure the amount is accurate and corresponds to the type of asset selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 4. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder. This could be you or a member of your household. Ensure the name matches the documentation you will attach as evidence.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 4. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. This could include real estate holdings, stocks, bonds, certificates of deposit, personal property, savings, retirement or educational accounts, checking accounts, or annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 4. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. dollars. Ensure the amount is accurate and corresponds to the type of asset selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 5. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder. This could be you or a member of your household. Ensure the name matches the documentation you will attach as evidence.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 5. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property (net value), Savings - Bank Account, Retirement or Educational Account, Checking - Bank Account, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 5. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. Dollars. Ensure the amount is accurate and corresponds to the asset type selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 6. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder, which could be you or a member of your household. This should match the name on any supporting documents.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 6. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset you are declaring from the provided list. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property (net value), Savings - Bank Account, Retirement or Educational Account, Checking - Bank Account, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 6. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the asset you are declaring in U.S. Dollars. Ensure the amount is accurate and corresponds to the asset type selected.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Fill out the table below regarding the assets available to you (do not include any assets from any individuals names in Part 2.) Attach evidence showing you have these assets. Row 7. Enter Full Name of Asset Holder (you or your household member) | Text |
Enter the full name of the asset holder, which could be you or a member of your household. This should match the name on any supporting documents.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 7. Select the type of Asset from the list of Assets | ComboBox |
Select the type of asset from the provided list that you own. Options include Real Estate Holdings, Stocks, Bonds, Certificates of Deposit, Personal Property, Savings, Retirement or Educational Account, Checking, and Annuities.
Real Estate Holdings
N/A
Stocks, Bonds, Certificates of Deposit
Personal Property (net value)
Savings - Bank Account
Retirement or Educational Account
Checking - Bank Account
Annuities
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Row 7. Enter the Amount (Cash Value) (in U. S. Dollars) | Text |
Enter the cash value of the selected asset in U.S. Dollars. This should be the current market value of the asset.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Enter the Current Cash Value (in U. S. Dollars) | Text |
Enter the current cash value of your assets in U.S. Dollars. This should reflect the total value of all your assets.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Assets. 19. Enter the Total (in U. S. Dollars) | Text |
Enter the total value of all your assets in U.S. Dollars. This should be the sum of the cash values of all your assets.
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| Financial Responsibility for Other Beneficiaries | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 20. Have you previously submitted a Form I 1 34 on behalf of a person other than the beneficiary listed on this Form I-134? Check this box for Yes | CheckBox |
Check this box if you have previously submitted a Form I-134 on behalf of a person other than the beneficiary listed on this form.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 20. Have you previously submitted a Form I 1 34 on behalf of a person other than the beneficiary listed on this Form I-134? Check this box for No | CheckBox |
Check this box if you have not previously submitted a Form I-134 on behalf of a person other than the beneficiary listed on this form.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 21. Person 1. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of the first person for whom you have previously submitted a Form I-134.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 21. Person 1. Enter Given Name (First Name) | Text |
Enter the given name (first name) of the first person for whom you have previously submitted a Form I-134.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 21. Person 1. Enter Middle Name | Text |
Enter the middle name of the first person for whom you have previously submitted a Form I-134.
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| Immigration Status | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. If a Lawful Permanent Resident. Enter the 9 digit Alien Registration Number (A Number) | Text |
Enter the 9-digit Alien Registration Number (A Number) if you are a Lawful Permanent Resident.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. What is your current immigration status? Provide documentation as provided in the instructions. Check this box for Nonimmigrant | CheckBox |
Check this box if your current immigration status is Nonimmigrant. Provide documentation as specified in the instructions.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. If a Nonimmigrant. Enter the 11 digit Form I-94 Arrival-Departure Record Number | Text |
Enter the 11-digit Form I-94 Arrival-Departure Record Number if you are a Nonimmigrant.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. Enter Other immigration status | Text |
Enter your current immigration status if it is not listed among the provided options.
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| Intent to Provide Support | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Intent to Provide Specific Contributions to the Beneficiary. 23. Explain the contribution. For example, if you intend to furnish room and board, state for how long. If you intend to provide 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. If you need additional space, use Part 8. Additional Information | Text |
Explain the specific contributions you intend to provide to the beneficiary. Include details such as duration and amount if providing money.
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| Interpreter Information | ||
| Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (if filing Form I- 1 34 on his or her own behalf). 2. Enter the full name of Interpreter | Text |
Enter the full name of the interpreter who assisted you in completing this form.
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| Interpreter's Certification | ||
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Signature. Interpreter's Certification. I certify, under penalty of perjury, that: I am fluent in English and Enter the fluent language. This is is the same language specified in Part 4. or in Part 5., Item B. in Item Number 1., and I have read to this individual agreeing to financially support the beneficiary in the identified language every question and instruction on this declaration and his or her answer to every question. The individual agreeing to financially support the beneficiary informed me that he or she understands every instruction, question, and answer on the declaration, including the Certification of the Individual Agreeing to Financially Support the Beneficiary, and has verified the accuracy of every answer | Text |
Enter the language in which the interpreter is fluent and has used to read the declaration to the individual agreeing to financially support the beneficiary.
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| Interpreter's Contact Information | ||
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Enter the Street Number and Name | Text |
Enter the street number and name of the interpreter's mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Check this box for Apartment | CheckBox |
Check this box if the interpreter's mailing address includes an apartment.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Check this box for Suite | CheckBox |
Check this box if the interpreter's mailing address includes a suite.
|
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Check this box for Floor | CheckBox |
Check this box if the interpreter's mailing address includes a floor.
|
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number of the interpreter's mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. Enter the City or Town | Text |
Enter the city or town of the interpreter's mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. For U. S. Address. select the State from the list of States | ComboBox |
Select the state from the list for the interpreter's U.S. mailing address.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit zip code for the interpreter's U.S. mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. For International Address. Enter the Postal Code | Text |
Enter the postal code for the interpreter's international mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. For International Address. Enter the Province | Text |
Enter the province for the interpreter's international mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Mailing Address. 3. For International Address. Enter the Country | Text |
Enter the country for the interpreter's international mailing address.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Contact Information. 4. Enter Interpreter's Daytime Telephone Number | Text |
Enter the interpreter's daytime telephone number.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Contact Information. 5. Enter Interpreter's Mobile Telephone Number | Text |
Enter the interpreter's mobile telephone number.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Contact Information. 6. Enter Interpreter's Email Address | Text |
Enter the interpreter's email address.
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| Interpreter's Information | ||
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. 1. Enter the Interpreter's Given Name (First Name) | Text |
Enter the given name (first name) of the interpreter.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. 1. Enter the Interpreter's Family Name (Last Name) | Text |
Enter the family name (last name) of the interpreter.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. 2. Enter the Interpreter's Business or Organization Name | Text |
Enter the business or organization name of the interpreter. Maximum length is 34 characters.
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| Interpreter's Signature | ||
| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Signature. 7. Enter the Signature. This field cannot be completed electronically | Text |
Interpreter must sign here. This field cannot be completed electronically.
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| Part 6. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. Interpreter's Signature. 7. Enter the Date of Signature. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of the interpreter's signature in the format MM/DD/YYYY.
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| Place of Birth | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 7. Place of Birth. Enter Country | Text |
Enter the country where you were born.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 7. Place of Birth. Enter State or Province | Text |
Enter the state or province where you were born.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 7. Place of Birth. Enter City or Town | Text |
Enter the city or town where you were born.
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| Pre-populated Information | ||
| Part 8. Additional Information. No Entry. 2. Alien Registration Number (A. Number). This field is pre-populated from Page 1 | Text |
This field is pre-populated with the Alien Registration Number (A-Number) from Page 1.
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| Part 8. Additional Information. If you need extra space to provide any additional information within this declaration, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this declaration or attach a separate sheet of paper. Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. No Entry 1. Given Name (First Name) (pre-populated from page 1) | Text |
This field is pre-populated with the given name (first name) from Page 1. Use this space to provide any additional information within this declaration. If more space is needed, make copies of this page or attach a separate sheet of paper.
|
| Part 8. Additional Information. If you need extra space to provide any additional information within this declaration, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this declaration or attach a separate sheet of paper. Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. No Entry 2. Family Name (Last Name) (pre-populated from page 1) | Text |
This field is pre-populated with the family name (last name) from Page 1. Use this space to provide any additional information within this declaration. If more space is needed, make copies of this page or attach a separate sheet of paper.
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| Preparer Information | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Full Name. 1. Enter Preparer's Given Name (First Name) | Text |
Enter the first name of the person who prepared this declaration, if different from the individual agreeing to financially support the beneficiary.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Provide the following information about the preparer. Preparer's Full Name. 1. Enter Preparer's Family Name (Last Name) | Text |
Enter the last name of the person who prepared this declaration, if different from the individual agreeing to financially support the beneficiary.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Full Name. 2. Enter Preparer's Business or Organization Name | Text |
Enter the business or organization name of the person who prepared this declaration, if applicable.
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| Preparer Mailing Address | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Enter the Street Number and Name | Text |
Enter the street number and name of the mailing address of the person who prepared this declaration.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Check this box for Apartment | CheckBox |
Check this box if the preparer's mailing address includes an apartment.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Check this box for Suite | CheckBox |
Check this box if the preparer's mailing address includes a suite.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Check this box for Floor | CheckBox |
Check this box if the preparer's mailing address includes a floor.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number of the preparer's mailing address.
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| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. Enter the City or Town | Text |
Enter the city or town of the preparer's mailing address.
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| Preparer's Certification | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Certification. By my signature, I certify, under penalty of perjury, that I prepared this declaration at the request of the individual agreeing to financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself). The individual agreeing to financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself) then reviewed this completed declaration and informed me that he or she understands all of the information contained in, and submitted with, his or her declaration, including the Certification of the Individual Agreeing to Financially Support the Beneficiary, and that all of this information is complete, true, and correct. I completed this declaration based only on information that the individual agreeing to financially support the beneficiary provided to me or authorized me to obtain or use. Preparer's Signature. 8. Enter the Signature. This field cannot be completed electronically | Text |
Enter the signature of the person who prepared this declaration, certifying that the information provided is complete, true, and correct. This field cannot be completed electronically.
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| Preparer's Contact Information | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Contact Information. 4. Preparer's Daytime Telephone Number | Text |
Enter the preparer's daytime telephone number.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Contact Information. 5. Preparer's Mobile Telephone Number | Text |
Enter the preparer's mobile telephone number.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Contact Information. 6. Preparer's Email Address | Text |
Enter the email address of the person who prepared this declaration, if different from the individual agreeing to financially support the beneficiary.
|
| Preparer's Mailing Address | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. For U. S. Address. select the State from the list of States | ComboBox |
Select the U.S. state from the provided list where the preparer resides.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit ZIP code for the preparer's U.S. mailing address.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. For International Address. Enter the Postal Code | Text |
Enter the postal code for the preparer's international mailing address.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. For International Address. Enter the Province | Text |
Enter the province for the preparer's international mailing address.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Mailing Address. 3. For International Address. Enter the Country | Text |
Enter the country for the preparer's international mailing address.
|
| Preparer's Signature | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Signature. 8. Enter the Date of Signature. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of the preparer's signature in the format MM/DD/YYYY.
|
| Preparer's Statement | ||
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Statement. 7. A. Check this box for I am not an attorney or accredited representative but have prepared this declaration on behalf of the individual agreeing to financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself) and with that individual's consent | CheckBox |
Check this box if you are not an attorney or accredited representative but have prepared this declaration on behalf of the individual agreeing to financially support the beneficiary, with that individual's consent.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Statement. 7. B. Check this box for I am an attorney or accredited representative and my representation of the individual agreeing to financially support the beneficiary (which is the beneficiary if filing on behalf of him or herself) in this case extends or does not extend beyond the preparation of this declaration | CheckBox |
Check this box if you are an attorney or accredited representative and your representation of the individual agreeing to financially support the beneficiary extends or does not extend beyond the preparation of this declaration.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Statement. 7. B. Check this box for representation that extends beyond the preparation of this declaration | CheckBox |
Check this box if your representation extends beyond the preparation of this declaration.
|
| Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if Other Than the Individual Agreeing to Financially Support the Beneficiary. Preparer's Statement. 7. B. Check this box for representation that does not extend beyond the preparation of this declaration | CheckBox |
Check this box if your representation does not extend beyond the preparation of this declaration.
|
| Support Intent | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Intent to Provide Specific Contributions to the Beneficiary. 23. Check this box for I intend to make specific contributions to the support of the beneficiary named in Part 2 | CheckBox |
Check this box if you intend to make specific contributions to the support of the beneficiary named in Part 2.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Intent to Provide Specific Contributions to the Beneficiary. 23. Check this box for I do not intend to make specific contributions to the support of the beneficiary named in Part 2 | CheckBox |
Check this box if you do not intend to make specific contributions to the support of the beneficiary named in Part 2.
|
| Supporter Certification | ||
| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. If you are filing Form I-134 on behalf of someone else (the beneficiary listed in Part 2.), complete and sign Part 5. If you are the beneficiary and are filing Form I- 1 34 on your own behalf, type or print N / A in Item Numbers 1. to 6. NOTE: Read the Penalties section of the Form I-134 Instructions before completing this section. Statement of Individual Agreeing to Financially Support the Beneficiary. NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. A. I, as the individual agreeing to financially support the beneficiary, certify the following: Check this box for I can read and understand English, and I have read and understand every question and instruction on this declaration and my answer to every question | CheckBox |
Check this box if you, as the individual agreeing to financially support the beneficiary, can read and understand English and have read and understood every question and instruction on this declaration.
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| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Statement of Individual Agreeing to Financially Support the Beneficiary. 1. B. Enter the language in which you are fluent | Text |
Enter the language in which you are fluent.
|
| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Statement of Individual Agreeing to Financially Support the Beneficiary. 1. B. Check this box for The interpreter named in Part 6. read to me every question and instruction on this declaration and my answer to every question in a language I am fluent and I understand | CheckBox |
Check this box if the interpreter named in Part 6 read to you every question and instruction on this declaration and your answer to every question in a language you are fluent in and understand.
|
| Supporter Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Provide 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 8. Additional Information. Row 2. Enter Family Name (Last Name) | Text |
Enter all other family names (last names) you have ever used, including aliases, maiden name, and nicknames. If you need extra space, use Part 8. Additional Information.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Row 1. Enter Middle Name | Text |
Enter all other middle names you have ever used.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Row 1. Enter Given Name (First Name) | Text |
Enter all other given names (first names) you have ever used.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Provide 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 8. Additional Information. Row 1. Enter Family Name (Last Name) | Text |
Enter all other family names (last names) you have ever used, including aliases, maiden name, and nicknames. If you need extra space, use Part 8. Additional Information.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Income. 14. Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you financially support (do not include any individuals named in Part 2.). Information about assets that are not based on employment should be added in Item Number 17. and not in Item Number 14. Row 4. Enter Full Name (First, Middle, Last) (do not include any individuals named in Part 2.) | Text |
Enter the full name (First, Middle, Last) of the individual agreeing to financially support the beneficiary, excluding any individuals named in Part 2.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 4. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of the individual agreeing to financially support the beneficiary in the format MM/DD/YYYY.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 4. Enter Relationship to the Individual Agreeing to Financially Support (Type or print Self for Individual Agreeing to Financially Support the Beneficiary) | Text |
Enter the relationship of the individual to the beneficiary. If the individual is the one agreeing to financially support the beneficiary, type or print 'Self'.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Income. 14. Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you financially support (do not include any individuals named in Part 2.). Information about assets that are not based on employment should be added in Item Number 17. and not in Item Number 14. Row 5. Enter Full Name (First, Middle, Last) (do not include any individuals named in Part 2.) | Text |
Enter the full name (First, Middle, Last) of the individual agreeing to financially support the beneficiary, excluding any individuals named in Part 2.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 5. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of the individual agreeing to financially support the beneficiary in the format MM/DD/YYYY.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 5. Enter Relationship to the Individual Agreeing to Financially Support (Type or print Self for Individual Agreeing to Financially Support the Beneficiary) | Text |
Enter the relationship of the individual agreeing to financially support the beneficiary. If you are the individual providing support, type or print 'Self'.
|
| Supporter Mailing Address | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Enter the In Care of Name (if any) | Text |
Enter the 'In Care of' name for the current mailing address, if applicable.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Enter the City or Town | Text |
Enter the city or town for the current mailing address.
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. For U. S. Address. select the State from the list of States | ComboBox |
Select the state for the current U.S. mailing address from the provided list of states.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
|
| Supporter's Contact Information | ||
| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Contact Information of Individual Agreeing to Financially Support the Beneficiary. 6. Enter Email Address | Text |
Enter the email address of the individual agreeing to financially support the beneficiary.
|
| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Contact Information of Individual Agreeing to Financially Support the Beneficiary. 4. Enter Mobile Telephone Number | Text |
Enter the mobile telephone number of the individual agreeing to financially support the beneficiary. Maximum length is 15 characters.
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| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Contact Information of Individual Agreeing to Financially Support the Beneficiary. 3. Enter Daytime Telephone Number | Text |
Enter the daytime telephone number of the individual agreeing to financially support the beneficiary. Maximum length is 15 characters.
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| Supporter's Employment Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Enter the Street Number and Name | Text |
Enter the street number and name of the current employer's address for the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Check this box for Apartment | CheckBox |
Check this box if the current employer's address includes an apartment number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Check this box for Suite | CheckBox |
Check this box if the current employer's address includes a suite number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Check this box for Floor | CheckBox |
Check this box if the current employer's address includes a floor number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number of the current employer's address for the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. Enter the City or Town | Text |
Enter the city or town of the current employer's address for the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. For U. S. Address. select the State from the list of States | ComboBox |
Select the state from the list of states for the current employer's address if it is a U.S. address.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Employment Information. 13. Current Employer's Address. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit zip code for the current employer's address if it is a U.S. address.
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| Supporter's Financial Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Income. 14. Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you financially support (do not include any individuals named in Part 2.). Information about assets that are not based on employment should be added in Item Number 17. and not in Item Number 14. Row 2. Enter Full Name (First, Middle, Last) (do not include any individuals named in Part 2.) | Text |
Enter the full name (First, Middle, Last) of the individual you financially support, excluding any individuals named in Part 2.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 2. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of the individual you financially support in the format MM/DD/YYYY.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 2. Enter Relationship to the Individual Agreeing to Financially Support (Type or print Self for Individual Agreeing to Financially Support the Beneficiary) | Text |
Specify the relationship of the individual you financially support to you. Type 'Self' if you are the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 2. Enter Income Contribution to the Beneficiary Annually (if none, type or print $0) | Text |
Enter the annual income contribution you provide to the beneficiary. If none, type or print $0.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Provide information about your income and assets. If you need additional space to complete any Item Number in this section, use the space provided in Part 8. Additional Information. Income. 14. Provide all of the information requested in the table below about yourself, all of your dependents, and any other individuals you financially support (do not include any individuals named in Part 2.). Information about assets that are not based on employment should be added in Item Number 17. and not in Item Number 14. Row 3. Enter Full Name (First, Middle, Last) (do not include any individuals named in Part 2.) | Text |
Enter the full name (First, Middle, Last) of another individual you financially support, excluding any individuals named in Part 2.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 3. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of another individual you financially support in the format MM/DD/YYYY.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Information. Income. Row 3. Enter Relationship to the Individual Agreeing to Financially Support (Type or print Self for Individual Agreeing to Financially Support the Beneficiary) | Text |
Specify the relationship of another individual you financially support to you. Type 'Self' if you are the individual agreeing to financially support the beneficiary.
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| Supporter's Financial Responsibility | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 21. Person 1. Enter the Alien Registration Number (A Number) | Text |
Enter the Alien Registration Number (A Number) for Person 1 who is financially responsible for other beneficiaries.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 21. Person 1. Enter the Date Submitted. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date submitted for Person 1 in the format MM/DD/YYYY.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 22. Person 2. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of Person 2 who is financially responsible for other beneficiaries.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 22. Person 2. Enter Given Name (First Name) | Text |
Enter the given name (first name) of Person 2 who is financially responsible for other beneficiaries.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 22. Person 2. Enter Middle Name | Text |
Enter the middle name of Person 2 who is financially responsible for other beneficiaries.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 22. Person 2. Enter the Alien Registration Number (A Number) | Text |
Enter the Alien Registration Number (A Number) for Person 2 who is financially responsible for other beneficiaries.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Financial Responsibility for Other Beneficiaries. 22. Person 2. Enter the Date Submitted. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date submitted for Person 2 in the format MM/DD/YYYY.
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| Supporter's Immigration Status | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. What is your current immigration status? Provide documentation as provided in the instructions. Check this box for U. S. Citizen | CheckBox |
Check this box if the individual agreeing to financially support the beneficiary is a U.S. Citizen. Provide documentation as specified in the instructions.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. What is your current immigration status? Provide documentation as provided in the instructions. Check this box for Lawful Permanent Resident | CheckBox |
Check this box if the individual agreeing to financially support the beneficiary is a Lawful Permanent Resident. Provide documentation as specified in the instructions.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Immigration Status. 10. What is your current immigration status? Provide documentation as provided in the instructions. Check this box for U. S. National | CheckBox |
Check this box if the individual agreeing to financially support the beneficiary is a U.S. National. Provide documentation as specified in the instructions.
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| Supporter's Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. If you are not the beneficiary named in Part 2., complete Part 3. If you are the beneficiary named in Part 2., type or print none or N/A in each field in Part 3. before moving to Part 4. 1. Current Legal Name (Do not provide a nickname). Enter Family Name (Last Name) | Text |
Enter the family name (last name) of the individual agreeing to financially support the beneficiary. If you are the beneficiary, type or print 'none' or 'N/A' in this field.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 1. Current Legal Name. (Do not provide a nickname) Enter Given Name (First Name) | Text |
Enter the given name (first name) of the individual agreeing to financially support the beneficiary. If you are the beneficiary, type or print 'none' or 'N/A' in this field.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 1. Current Legal Name. (Do not provide a nickname) Enter Middle Name | Text |
Enter the middle name of the individual agreeing to financially support the beneficiary. If you are the beneficiary, type or print 'none' or 'N/A' in this field.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Row 2. Enter Middle Name | Text |
Enter any other middle names used by the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 2. Other Names Used. Row 2. Enter Given Name (First Name) | Text |
Enter any other given names (first names) used by the individual agreeing to financially support the beneficiary.
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| Supporter's Mailing Address | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit ZIP code for the current mailing address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number for the current mailing address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Check this box for Floor | CheckBox |
Check this box if the current mailing address of the individual agreeing to financially support the beneficiary includes a floor number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Check this box for Suite | CheckBox |
Check this box if the current mailing address of the individual agreeing to financially support the beneficiary includes a suite number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Check this box for Apartment | CheckBox |
Check this box if the current mailing address of the individual agreeing to financially support the beneficiary includes an apartment number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. Enter the Street Number and Name | Text |
Enter the street number and name for the current mailing address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. For International Address. Enter the Postal Code | Text |
Enter the postal code for the international address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. For International Address. Enter the Province | Text |
Enter the province for the international address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 3. Current Mailing Address. For International Address. Enter the Country | Text |
Enter the country for the international address of the individual agreeing to financially support the beneficiary.
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| Supporter's Personal Information | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 6. Enter Date of Birth. Enter date as 2-digit month, 2-digit day, and 4 digit year | Text |
Enter the date of birth of the individual agreeing to financially support the beneficiary. Use the format MM/DD/YYYY.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 8. Enter 9 digit Alien Registration Number (A Number) (if any) | Text |
Enter the 9-digit Alien Registration Number (A Number) of the individual agreeing to financially support the beneficiary, if applicable.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. Other Information. 9. Enter 12 digit USCIS Online Account Number (if any) | Text |
Enter the 12-digit USCIS Online Account Number of the individual agreeing to financially support the beneficiary, if applicable.
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| Supporter's Physical Address | ||
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Enter the In Care of Name | Text |
Enter the 'In Care of' name for the physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Enter the City or Town | Text |
Enter the city or town of the physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. For U. S. Address. select the State from the list of States | ComboBox |
Select the state from the list of U.S. states for the physical address of the individual agreeing to financially support the beneficiary.
MN
NJ
PA
MH
ND
WV
MO
CA
GA
TX
VI
CO
MS
IL
DE
AK
PR
VA
NY
FM
NV
AR
NC
AE
CT
KY
HI
MI
MA
NH
ME
WI
MD
MT
VT
AZ
OH
IN
KS
RI
N/A
DC
WA
GU
SC
SD
ID
AP
OK
NE
IA
UT
PW
LA
AA
MP
NM
OR
WY
TN
FL
AL
AS
|
| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. For U. S. Address. Enter the 5 digit Zip Code | Text |
Enter the 5-digit zip code for the physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Enter the Apartment, Suite, or Floor Number | Text |
Enter the apartment, suite, or floor number for the physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Check this box for Floor | CheckBox |
Check this box if the address includes a floor number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Check this box for Suite | CheckBox |
Check this box if the address includes a suite number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Check this box for Apartment | CheckBox |
Check this box if the address includes an apartment number.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. Enter the Street Number and Name | Text |
Enter the street number and name for the physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. For International Address. Enter the Postal Code | Text |
Enter the postal code for the international physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. For International Address. Enter the Province | Text |
Enter the province for the international physical address of the individual agreeing to financially support the beneficiary.
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| Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in Part 2. 5. Physical Address. For International Address. Enter the Country | Text |
Enter the country for the international physical address of the individual agreeing to financially support the beneficiary.
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| Supporter's Statement | ||
| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Statement of Individual Agreeing to Financially Support the Beneficiary. 2. Check this box for At my request, the preparer named in Part 7., prepared this declaration for me based only upon information I provided or authorized | CheckBox |
Check this box if the preparer named in Part 7 prepared this declaration for you based only on information you provided or authorized.
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| Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to Financially Support the Beneficiary. Statement of Individual Agreeing to Financially Support the Beneficiary. 2. Enter the Full Name of the Preparer | Text |
Enter the full name of the preparer who helped you complete this declaration.
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