Affidavit of Support USCIS

Form I-134
Department of Homeland Security OMB No. 1615-0014
U.S. Citizenship and Immigration Services Expires 02/28/2021

► START HERE - Type or print in black ink.

Part 1. Information About You (the Sponsor) Sponsor's Physical Address

Your Full Name 5.a. Street Number N/A
and Name
1.a. Family Name Lefonse 5.b. Apt. Ste. Flr. N/A
(Last Name)
1.b. Given Name Jacob 5.c. City or Town N/A
(First Name)

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1.c. Middle Name Anthony 5.d. State N/A 5.e. ZIP Code N/A

5.f. Province N/A

Other Names Used
List all other names you have ever used, including aliases, 5.g. Postal Code N/A

Additional Information.
2.a. Family Name Lefonse
(Last Name)
2.b. Given Name Jake
(First Name)
2.c. Middle Name N/A
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maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 7.
5.h. Country

6.
N/A

Other Information
Date of Birth (mm/dd/yyyy)
7.a. Town or City of Birth
Sintra
08/11/1992
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Sponsor's Mailing Address
7.b. Country of Birth
3.a. In Care Of Name Portugal
N/A
8. Alien Registration Number (A-Number) (if any)
3.b. Street Number 123 Main Street ► A- 1 2 3 4 5 6 7 8 9
and Name
3.c. Apt. Ste. Flr. N/A 9. U.S. Social Security Number (if any)
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► 0 0 0 0 0 0 0 0 0
3.d. City or Town Orlando
10. USCIS Online Account Number (if any)
3.e. State FL 3.f. ZIP Code 10000 ► 9 9 9 9 9 9 9 9 9 9 9 9

3.g. Province N/A

Citizenship or Residency or Status
3.h. Postal Code N/A If you are not a U.S. citizen based on your birth in the United
States, or a non-citizen U.S. national based on your birth in
3.i. Country
American Samoa (including Swains Island), answer the
United States following as appropriate:
4. Are your mailing address and physical address the same? 11.a. I am a U.S. citizen through naturalization. My
Yes No Certificate of Naturalization number is
N/A
If you answered "No" to Item Number 4., provide your
physical address in Item Numbers 5.a. - 5.h. 11.b. I am a U.S. citizen through parent(s) or marriage.
My Certificate of Citizenship number is
N/A

Form I-134 02/13/19 Page 1 of 8

Part 1. Information About You (the Sponsor) Beneficiary's Physical Address
(continued)
8.a. Street Number Rua da Escola 20
11.c. I derived my U.S. citizenship by another method. and Name
(Provide an explain in Part 7. Additional 8.b. Apt. Ste. Flr. N/A
Information.)
11.d. I am a lawful permanent resident of the 8.c. City or Town Porto das Barcas
United States. My A-Number is
8.d. State N/A 8.e. ZIP Code N/A
► A- 1 2 3 4 5 6 7 8 9

11.e. I am a lawfully admitted nonimmigrant. My 8.f. Province N/A

Form I-94, Arrival-Departure Record Number is
8.g. Postal Code 7630-807
► N / A

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8.h. Country
12. I am N/A years of age and have resided in the United
Portugal
States since (Date) (mm/dd/yyyy) N/A
Beneficiary's Spouse (accompanying or following
Part 2. Information About the Beneficiary to join beneficiary)

(Last Name)
1.b. Given Name Tomas
(First Name)
1.c. Middle Name N/A

2. Date of Birth (mm/dd/yyyy)

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This affidavit is executed on behalf of the following person:
1.a. Family Name Duarte

07/31/2003
9.a. Family Name N/A

10.

11.
(Last Name)
9.b. Given Name N/A
(First Name)
9.c. Middle Name N/A

Date of Birth (mm/dd/yyyy)

Gender Male Female

N/A
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3. Gender Male Female
Beneficiary's Children
4. A-Number (if any)
Child 1
► A- N / A
12.a. Family Name N/A
5. Country of Citizenship or Nationality (Last Name)
Portugal 12.b. Given Name N/A
(First Name)
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6. Marital Status 12.c. Middle Name N/A

Single or Single, Never Married
13. Date of Birth (mm/dd/yyyy) N/A
Married
Divorced 14. Gender Male Female
Widowed
Child 2
Legally Separated
15.a. Family Name N/A
Marriage Annulled (Last Name)
Other N/A 15.b. Given Name N/A
(First Name)
7. Relationship to Sponsor 15.c. Middle Name N/A
Cousin
16. Date of Birth (mm/dd/yyyy) N/A

17. Gender Male Female

If you need additional space to complete this section, use the
space provided in Part 7. Additional Information.
Form I-134 02/13/19 Page 2 of 8
Part 3. Other Information About the Sponsor 7.a. I have life insurance in the sum of $ None

Employment Information 7.b. With a cash surrender value of

$ None
I am currently:

1.a. Employed as a/an Sales Real Estate Information

1.a.1. Name of Employer (if applicable) 8.a. I own real estate valued at $ 325,000
State Farm Insurance
8.b. I have mortgages or other debts amounting to
1.b. Self employed as a/an $ 223,000
N/A
My real estate is located at:

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Current Employer Address (if employed) 9.a. Street Number 123 Main St
and Name
2.a. Street Number 10 Universal Blvd 9.b. Apt. Ste. Flr. N/A
and Name
2.b. Apt. Ste. Flr. N/A 9.c. City or Town Orlando

2.c. City or Town

2.d. State FL

2.f. Province

2.g. Postal Code

2.h. Country
United States
Orlando

2.e. ZIP Code N/A

N/A

N/A
PL 9.d. State FL

Dependents' Information
9.e. ZIP Code 11111

The following persons are dependent upon me for support. If

you need extra space to complete this section, use the space
provided in Part 7. Additional Information.
10.a. Family Name Lefonse
(Last Name)
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10.b. Given Name Dianna
(First Name)
Income and Asset Information 10.c. Middle Name
3. My annual income is $ 46,500 11. Relationship to Me:
(If self-employed, I have attached a copy of my last income tax Spouse
return or report of commercial rating concern which I certify to
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be true and correct to the best of my knowledge and belief. See 12. Date of Birth (mm/dd/yyyy) 05/06/1994
Instructions for nature of evidence of net worth to be submitted.)
13. This person is:
4. Balance of all my savings and checking accounts in Wholly Dependent On Me For Support
United States-based financial institutions
Partially Dependent On Me For Support
$ 4,200

5. Value of my other personal property 14.a. Family Name Lefonse

(Last Name)
$ 24,000
14.b. Given Name James
6. Market value of my stocks and bonds (First Name)
$ 41,000 14.c. Middle Name Marcus

I have listed my stocks and bonds in Part 7. Additional 15. Relationship to Me:
Information (or attached a list of them), which I certify to be Child
true and correct to the best of my knowledge and belief.
16. Date of Birth (mm/dd/yyyy) 11/12/2018

Form I-134 02/13/19 Page 3 of 8

Part 3. Other Information About the Sponsor 28. Date of Birth (mm/dd/yyyy) 11/12/2018
(continued)
29. Date of Filing (mm/dd/yyyy) 02/01/2015
17. This person is:
Wholly Dependent On Me For Support 30.a. Family Name N/A
(Last Name)
Partially Dependent On Me For Support
30.b. Given Name N/A
(First Name)
18.a. Family Name N/A
(Last Name) 30.c. Middle Name N/A
18.b. Given Name N/A
(First Name) 31. Relationship to Me:
N/A
18.c. Middle Name N/A

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19. Relationship to Me: 32. Date of Birth (mm/dd/yyyy) N/A
N/A
33. Date of Filing (mm/dd/yyyy) N/A
20. Date of Birth (mm/dd/yyyy) N/A
34.a. Family Name N/A
21. This person is: (Last Name)

name below.)
22.a. Family Name N/A
(Last Name)
22.b. Given Name N/A
(First Name)
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Wholly Dependent On Me For Support
Partially Dependent On Me For Support

I have previously submitted affidavit(s) of support for the

following person(s). (If none, write "None" in the space for
34.b. Given Name N/A

36.

37.
(First Name)
34.c. Middle Name

35.
N/A
N/A

Relationship to Me:

Date of Birth (mm/dd/yyyy)

Date of Filing (mm/dd/yyyy)

N/A

N/A
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22.c. Middle Name N/A 38. I intend do not intend to make specific
contributions to the support of the person(s) named in
23. Date Submitted (mm/dd/yyyy) N/A Part 2.
(If you select "intend," indicate the exact nature and
24.a. Family Name N/A duration of the contributions you intend to make in
(Last Name) Part 7. Additional Information. For example, if you
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24.b. Given Name N/A intend to furnish room and board, state for how long and,
(First Name) if money, state the amount in U.S. dollars and whether it
24.c. Middle Name N/A is to be given in a lump sum, weekly or monthly, and for
how long.)
25. Date Submitted (mm/dd/yyyy) N/A

I have submitted a visa petition(s) to U.S. Citizenship and

Immigration Services on behalf of the following persons. (If
none, write “None” in the space for name below.)
26.a. Family Name Lefonse
(Last Name)
26.b. Given Name Dianna
(First Name)
26.c. Middle Name N/A

27. Relationship to Me:

Spouse

Form I-134 02/13/19 Page 4 of 8

Part 4. Sponsor's Statement, Contact I understand that USCIS may require me to appear for an
Information, Certification, and Signature appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
NOTE: Read the Penalties section of the Form I-134 biometrics, I will be required to sign an oath reaffirming that:
Instructions before completing this part.
1) I reviewed and provided or authorized all of the
information in my affidavit;
Sponsor's Statement
2) I understood all of the information contained in, and
NOTE: Select the box for either Item Number 1.a. or 1.b. submitted with, my affidavit; and
If applicable, select the box for Item Number 2.
3) All of this information was complete, true, and correct at
1.a. I can read and understand English, and I have read and the time of filing.
understand every question and instruction on this
I certify, under penalty of perjury, that I provided or authorized
affidavit and my answer to every question.
all of the information in my affidavit, I understand all of the

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1.b. The interpreter named in Part 5. read to me every information contained in, and submitted with, my affidavit, and
question and instruction on this affidavit and my that all of this information is complete, true, and correct.
answer to every question in
That this affidavit is made by me to assure the U.S. Government
N/A , that the person named in Part 2. will not become a public
a language in which I am fluent and I understood charge in the United States.

2.

3.
everything.

N/A

PL
At my request, the preparer named in Part 6.,

prepared this affidavit for me based only upon

information I provided or authorized.

Sponsor's Contact Information

Sponsor's Daytime Telephone Number
+1 407-555-1212
,
That I am willing and able to receive, maintain, and support the
person named in Part 2. I am ready and willing to deposit a
bond, if necessary, to guarantee that such persons will not
become a public charge during his or her stay in the United
States, or to guarantee that the above named persons will
maintain his or her nonimmigrant status, if admitted
temporarily, and will depart prior to the expiration of his or her
authorized stay in the United States.
That I understand that Form I-134 is an "undertaking" under
section 213 of the Immigration and Nationality Act, and I may
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be sued if the persons named in Part 2. become a public charge
4. Sponsor's Mobile Telephone Number (if any) after admission to the United States.
N/A That I understand that Form I-134 may be made available to any
Federal, State, or local agency that may receive an application
5. Sponsor's Email Address (if any)
from the persons named in Part 2. for Food Stamps,
N/A Supplemental Security Income, or Temporary Assistance to
Needy Families.
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Sponsor's Certification That I understand that if the person named in Part 2. does apply
for Food Stamps, Supplemental Security Income, or Temporary
Copies of any documents I have submitted are exact photocopies
Assistance for Needy Families, my own income and assets may
of unaltered, original documents, and I understand that USCIS or
be considered in deciding the person's application. How long
the Department of State may require that I submit original
my income and assets may be attributed to the persons named in
documents to USCIS or the Department of State at a later date.
Part 2. is determined under the statutes and rules governing
Furthermore, I authorize the release of any information from any
each specific program.
of my records that USCIS or the Department of State may need
to determine my eligibility for the immigration benefit I seek. I acknowledge that I have read the section entitled Sponsor and
Beneficiary Liability in the Instructions for this affidavit, and am
I further authorize release of information contained in this
aware of my responsibilities as a sponsor under the Social
affidavit, in supporting documents, and in my USCIS or the
Security Act, as amended, and the Food Stamp Act, as amended.
Department of State records to other entities and persons where
necessary for the administration and enforcement of U.S.
immigration laws. Sponsor's Signature
6.a. Sponsor's Signature

6.b. Date of Signature (mm/dd/yyyy)

Form I-134 02/13/19 Page 5 of 8

NOTE TO ALL SPONSORS: If you do not completely fill Interpreter's Certification
out this affidavit or fail to submit required documents listed in
the Instructions, USCIS or the Department of State may deny I certify, under penalty of perjury, that:
your affidavit.
I am fluent in English and N/A ,
which is the same language provided in Part 4., Item
Part 5. Interpreter's Contact Information, Number 1.b., and I have read to this sponsor in the identified
Certification, and Signature language every question and instruction on this affidavit and his
or her answer to every question. The sponsor informed me that
Provide the following information about the interpreter. he or she understands every instruction, question, and answer on
the affidavit, including the Sponsor's Certification, and has
Interpreter's Full Name verified the accuracy of every answer.

1.a. Interpreter's Family Name (Last Name) Interpreter's Signature

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N/A
7.a. Interpreter's Signature
1.b. Interpreter's Given Name (First Name) N/A
N/A
7.b. Date of Signature (mm/dd/yyyy) N/A
2. Interpreter's Business or Organization Name (if any)

3.b.
N/A

Interpreter's Mailing Address

3.a. Street Number
and Name
Apt.

3.c. City or Town

N/A

Ste.

N/A
Flr. N/A
PL Part 6. Contact Information, Statement,
Declaration, and Signature of the Person
Preparing this Affidavit, if Other Than the
Sponsor
Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)
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3.d. State N/A 3.e. ZIP Code N/A
N/A
3.f. Province N/A
1.b. Preparer's Given Name (First Name)
3.g. Postal Code N/A N/A
3.h. Country 2. Preparer's Business or Organization Name (if any)
N/A N/A
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Interpreter's Contact Information Preparer's Mailing Address

4. Interpreter's Daytime Telephone Number 3.a. Street Number N/A
and Name
N/A
3.b. Apt. Ste. Flr. N/A
5. Interpreter's Mobile Telephone Number (if any)
N/A 3.c. City or Town N/A
6. Interpreter's Email Address (if any) 3.d. State N/A 3.e. ZIP Code N/A
N/A
3.f. Province N/A

3.g. Postal Code N/A

3.h. Country
N/A

Form I-134 02/13/19 Page 6 of 8

Part 6. Contact Information, Statement,
Declaration, and Signature of the Person
Preparing this Affidavit, if Other Than the
Sponsor (continued)

Preparer's Contact Information

4. Preparer's Daytime Telephone Number
N/A
5. Preparer's Fax Number
N/A

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6. Preparer's Email Address (if any)
N/A

Preparer's Statement
7.a.

7.b.
PL
I am not an attorney or accredited representative but
have prepared this affidavit on behalf of the sponsor
and with the sponsor's consent.
I am an attorney or accredited representative and my
representation of the sponsor in this case
extends does not extend beyond the
preparation of this affidavit.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this affidavit, you may be obliged to
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submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this application.

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
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prepared this affidavit at the request of the sponsor. The sponsor

then reviewed this completed affidavit and informed me that he
or she understands all of the information contained in, and
submitted with, his or her affidavit, including the Sponsor's
Certification, and that all of this information is complete, true,
and correct. I completed this affidavit based only on information
that the sponsor provided to me or authorized me to obtain or use.

Preparer's Signature
8.a. Preparer's Signature
N/A

8.b. Date of Signature (mm/dd/yyyy) N/A

Form I-134 02/13/19 Page 7 of 8

Part 7. Additional Information 5.a. Page Number 5.b. Part Number 5.c. Item Number

If you need extra space to provide any additional information

within this affidavit, use the space below. If you need more 5.d.
space than what is provided, you may make copies of this page
to complete and file with this affidavit or attach a separate sheet
of paper. Type or print your name and A-Number (if any) at
the top of each sheet; type or print the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.

Your Full Name

1.a. Family Name Lefonse

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(Last Name)
1.b. Given Name Jacob
(First Name)
1.c. Middle Name Anthony

2. A-Number (if any) 6.a. Page Number 6.b. Part Number 6.c. Item Number

3.a. Page Number

3.d.
► A- N / A

3.b. Part Number

PL 3.c. Item Number

6.d.
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7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.
4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

Form I-134 02/13/19 Page 8 of 8