Affidavit of Support [PDF]

Affidavit of SupportAnswer all items (type or print clearly in ink):I, __________________________________________________, residing at_________________________________________(Deponent’s Name)(Street)______________________________________________________________________________________________________.(City) (State) (Country)Being Duly Sworn, Depose and Say:1. I was born on _____________________________ at this location_______________________________________________.(Date)(City, Region, Country)If you are not a native born United States citizen, answer the following:a. I do live in the United States I do not live in the United Statesb. I am a United States citizen through naturalization _____ yes _____ noc. I am a lawful permanent resident of the United States _____ yes _____ no2. That this affidavit is executed on behalf of:Student's Name: ____________________________________________________________ Sex _________ Age _______Citizen of: _________________________________________________________________ Single _____ Married _______Relationship to me is _____________________________________________________, and resides at _________________________________________________________________________________________________________________3. That this affidavit is made by me for the purpose of assuring the United States Government that the person named in Item 2will not become a public charge in the United States.4. That I am willing and able to support the person named in Item 2.5. That I understand this affidavit will be binding upon me for a period of four (4) years (if other, number of years _______) andthat the information and documentation provided by me may be made available to the Department of Justice.6. That I am employed by (business) ________________________________________________________________________at ________________________________________________________________________________________________.I derive an annual income of US $ ____________and attach my employer's employment verification on business letterhead.I have on deposit in bank savings US $ ______________________________and attach the bank's statement of verification.I have other personal property, the value of which is US $ ___________________________________________________.I have stocks and bonds with the following market value US $ ______________________, as indicated on the attached list.I own real estate, located at ______________________________________________________________________ valuedat US $ ____________________, with other mortgages or other encumbrances amounting to US $ __________________.

7. That the following persons are dependent upon me for support:Name of PersonWhollydependentPartiallyDependentAgeRelationship to Me8. I have previously submitted affidavit(s) of support. Yes No If yes, I have previously submitted affidavit(s) of support for thefollowing person(s) in the amount(s) of: ______________________________________________________________________________________________________________________________________________________________________.9. That I have submitted visa petition to the Immigration and Naturalization Service on behalf of (give name, relationship anddate): _______________________________________________________________________________________________________________________________________________________________________________________________.10. That I DO INTEND to make specific contributions to the support of the person named in Item 2. (Indicate in US $ the exactnature of your contribution and for how many years) __________________________________________________________________________________________________________________________________________________________.Oath or Affirmation of DeponentI affirm that I know the contents of this affidavit signed by me and the statements attached are true and correct.Signature of deponent___________________________________________________________________________________________________.Subscribed and affirmed before me this _______________________ day of __________________________, 20____________,Signature of Officer Administering Oath_____________________________________________________________________________________.Title _______________________________________________________ Commission Expires ________________________.If affidavit prepared by other than deponent, please complete the following:I declare that this document was prepared by me at the request of the deponent and is based on all information of which I haveknowledge.Signature _________________________________________________________ Date _______________________________.Address_____________________________________________________________________________________________________.