Affidavit of Support uscis Form 1-134 Department of Homeland Security OMB No. 1615-0014 USS. Citizenship and Immigration Services Expires 02/28/2021 > START HERE- Type or pr black ink. [Part 1. Information About You (the Sponsor) Your Full Name La. Family Name Family Name [botnca 1b. Given Name [Gregory First Name) ‘Sponsor's Physical Address S.a, Street Number and Name sb. Clan. (ste Sc. City or Town Orr. Le. Middle Name [Ray Sd. State See. ZIP Code Other Names Used List all other names you have ever used, including aliases, ‘maiden name, and nicknames. Ifyou need extra space to 5 Province Sg, Postal Code Sh. Country complete use the space provided in Part 7. ‘Additional tion. 2a, Family Name . (LastName) Other Information 2b. Given Name (First Name) 6 Date of Birth (mm/dd/yyyy) [02/10/1991 Le. Middle Name 1. Town or City ofBith penviite ‘Sponsor's Mailing Address 3. InCare OF Name 3b. Street Number Steet Number (598 20th St 3e Clam Ose. Ort 3d. City orTown [virginia Beach County of Binh 9. US. Social Security Number (if any) pia a9908223 10, USCIS Online Account Number (if any) Se. State[ VA] 3.6 ZIP Code [23451 >| 3g. Province ‘uh. Postal Code 3a Country [usa 4. Are your mailing address and physical address the same? Bi Yes [No Ifyou answered "No" to Item Number 4., provide your physical address in Item Numbers 5.2. - 5.b. Citizenship or Residency or Status Ifyou are not a U.S. citizen based on your birth in the United States, ora non-citizen U.S. national based on your birth in ‘American Samoa (including Swains Island), answer the following as appropriate: 11.2, [] 1am a US. citizen through naturalization, My Certificate of Naturalization number is 11.b. [] tam a US. citizen through parent(s) or marriage. My Certificate of Citizenship number is Form F134 02/13/19 Page 1 of 8[Part 1. Information About You (the Sponsor) (continued) 114. (| derived my US. (Provide an exp Information ) izenship by another method. Part 7, Additional 11.4, [1am a lawful permanent resident of the ‘United States. My A-Number i mA 112, 2) Lama lawfully admited nonimmigrant. My Form 54, Atval-Departre Record Number f > 12, 1am [~_ ]years of age and have resided in the United States since (Date) (mm/ddiyyyy) [Part 2, Information About the Beneficiary Beneficiary's Physical Address 8a, Street Number andName ZA ab. Can. Ose. OF. Be. CiyorTown [Faounde 4, sute[ 7] se aPcodel id 8. Province 8g. ES = Bh. Country Beneficiary's Spouse (accompanying or following t0 join beneficiary) 9a, Family Name This affidavit is executed on behalf ofthe following person: (tartare) La, Family Name 9.b. Given Name (LastName) ide (rst Name) Lb. Given Name se. Mite Ne (First Name) [Emmanuel 9c, Middle Name Middle Name [Neison Enyegue 2, Date of Birth (mm/ddiyyyy) [oa/aa/ag95 3 Gender Male [1] Female Date of Birth (mmvdd/yyyy) 11, Gender] Male (Female Beneficiary's Children 4 A-Number(fany) — . 12a, Family Name 5 Country of Citizenship or Nationality (Last Name) pao 12, Given Name (First Name) 6 Marital Staus LX Single or Single, Never Married 12.4, Middle Name 13, Date of Birth (mm/dd/yyyy) (Married Dbivorced Gender [] Male [] Female Cl Widowed con van Ci tezaly Separated 15.a. Family Name_ (vargas tenia Cote [ 15h. Goethe 1 Renin Soe ee tend For F134 02/13/19 16. Date of Birth (mm/dd/yyyy) 17. Gender []Male [] Female Ifyou need additional space to complete ths section, use the space provided in Part 7. Additional Information, Page 2 0f8[Part 3. Other Information About the Sponsor Employment Information Tam currently: 1a. J] Employed as a/an [rieutenant: - Name of Employer (if applicable) lus Navy. 1.b. [] Selfemployed as alan ‘7a. Ihave life insurance in the sum of |S ‘7.b. With a cash surrender value of Real Estate Information 8a. Townreal estate valued at $ 8.b. I have mortgages or other debts amount s My realestate is located at: 9.a, Street Number Current Employer Address (if employed) Sopa Nun 2a, Street Number Sweet Number [1609 SEABEE DR 9b Cant Ose. Orie. 2b. Cap. Ost. Orie. 9... City or Town 2e. CiyorTown [Virginia Beach 9d. State 9. ZIP Code| 24. Suie[ va | 26. ZIP Code [25489 Dependents" Information 2. Province 2g. Postal Code 2.4, Country [usa Income and Asset Information The following persons are dependent upon me for suppor. If you need extra space to complete this section, use the space provided in Part 7. Additional Information 10.2, Family Name (LastName) LS=PBY 10. Given Name (FirstName) [Batty 10.c. Middle Name 3. [70,000.00 1. Relationship to Me: (it set-employed, Ihave attached a copy of my las income tax return or report of commercial rating concer which I certify to be true and corect othe best of my knowledge and belief. See Instructions for nature of evidence of net worth tobe submited) 4. Balance ofall my savings and checking accounts in United States-based financial institutions [rite 12. Date of Birth (mm/ddlyyyy) [ossoa/ag92 13. This person C1 Wholly Dependent On Me For Support Bx] Partially Dependent On Me For Support Family Name (Last Name) s[40, 000.00 5. Value of my other personal prope [40,000.00 6 Market value of my stocks and bonds [75,000.00 14. Middle Name ‘have listed my stocks and bonds in Part 7. Additional Information (or attached a list of them), which I certify to be true and correct tothe best of my knowledge and belief. 15. Relationship to Me: 16. Date of Birth (mm/dd/yyyy) Form F134 0213719 Page 3 0f8[Part 3. Other Information About the Sponsor (continued) 17, This person is: Cy Wholly Dependent On Me For Support C Partially Dependent On Me For Support 28, Date of Birth (mm/dd/yy) 29, Date of Filing (mm/dd/yyyy) 30.2. Family Name (Last Name) 30.b. Given Name (First Name) 18.a. Family Name (Cathar) 30, Mile Name 8° Gist Na) 31. Relationship to Me: 18.6. Middle Name 19, Relationship to Me: 20. Date of Birth (mmiddiyyyy) 21, This persons: D1 Wholly Dependent On Me For Support Partially Dependent On Me For Support {have previously submited affidavits) of support forthe following persons). (If one, write "None" inthe space for name below.) 22, Family Name (Last Name) 22.b. Given Name (First Name) 22.¢, Middle Name 23, Date Submitted (mm/ddiyyyy) * (ashame). 24.b. Given Name (First Name) 24.¢. Middle Name 25. Date Submitted (mm/dd/yy) have submitted a visa petition(s) to U.S. Citizenship and Immigration Services on behalf ofthe following persons. (If none, write “None” inthe space for name below.) 26.2, Family Name [yong (Last Name) 26.b. Given Name (First Name) 26., Middle Name 27. Relationship to Me: 32, Date of Birth (mm/ddiyyyy) 33. Date of Filing (mm/dd/yyyy) 34.a, Family Name (Last Name) 34.b. Given Name First Name) ‘34. Middle Name ‘38. Relationship to Me: 36. Date of Birth (mm/ddiyyyy) 37. Date of Filing (mmi/ddiyyyy) 38. 1 BRlintend [] do not imend to make specific contributions tothe suppor ofthe person(s) named in Part 2. (ifyou select "intend" indicate the exact nature and duration ofthe contributions you intend to make in Part 7. Additional Information. For example, if you tend to furnish room and board, state for how long and, ‘money, state the amount in US. dollars and wiether it isto be given in a lump sum, weekly or monthly and for how long.) Form F134 021319 Page 4 of8Part 4. Sponsor's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section ofthe Form 1-134 Instructions before completing this par. ‘Sponsor's Statement NOTE: Select the box for either Hem Number L.a, or Lb, I applicable, select the box for Item Number 2. | can read and understand English, and I have read and understand every question and instruction on this affidavit and my answer to every question, ‘The interpreter named in Part 5. read to me every question and instruction on this affidavit and my answer to every question in ‘Tangoage in which Tam Fluent and 1 understood everything. [7 Atny request, the preparer named in Part 6. prepared this affidavit for me based only upon information | provided or authorized, Sponsor's Contact Information 3. Sponsor's Daytime Telephone Number [2736997099 4. Sponsor's Mobile Telephone Number (if any) [8736997099 Sponsor's Email Address (if any) lereg.detuca32¢gmail.com Sponsor's Certification Copies of any documents | have submitted are exact photocopies ‘of unaltered, original documents, and I understand that USCIS or the Department of State may require that | submit original documents to USCIS or the Department of State at later dat Furthermore, I authorize the release of any information from any ‘of my records that USCIS or the Department of State may need to determine my eligibility forthe immigration benefit | seek | further authorize release of information contained inthis affidavit, in supporting documents, and in my USCIS or the Department of State records to other entities and persons where necessary for the adminis immigration laws. and enforcement of US. [understand that USCIS may require me to appear for an appointment to take my biometrics fingerprints, photograph, and/or signature) and, at that time, if | am required to provide ‘biometrics, | will be required to sign an oath reaffirming that 1) | reviewed and provided or authorized all ofthe information in my affidavit; 2) | understood all ofthe information contained in, and submitted with, my affidavit; and 3) All ofthis info the time of mation was complete, true, and correct at | certify, under penalty of perjury, that | provided or authorized all ofthe information in my affidavit, I understand all ofthe information contained in, and submitted with, my affidavit, and that all ofthis information is complete, true, and correct. That this affidavit is made by me to assure the U.S. Government thatthe person named in Part 2. will not become a public charge inthe United States ‘That | 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 orto guarantee thatthe 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 stayin the United States. ‘That | understand that Form I-134 isan “undertaking” under section 213 of the Immigration and Nationality Act, and I may bbe sued ifthe persons named in Part 2, become a public charge after admission to the United States That | understand that Form I-134 may be made availabe to any Federal, State, or local agency that may receive an application from the persons named in Part 2, for Food Stamps, Supplemental Security Income, of Temporary Assistance 10 Needy Families ‘That | understand that ifthe person named in Pat 2. does apply for Food Stamps, Supplemental Security Income, or Temporary Assistance for Needy Families, my own income and assets may be considered in deciding the person's application. How long my income and assets may be attributed tothe persons named in Part 2 is determined under the statutes and rules governing cach specific program, | acknowledge that I have read the section entitled Sponsor and Beneficiary Liability inthe Instructions for this affidavit, and am aware of my responsibilities asa sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended. Sponsor's Signature 6.a, Sponsor's Signature [oayox/zo18 Page SofNOTE TO ALL SPONSORS: Ifyou do not completely fil __Interpreter's Certificatio ‘out this affidavit or fil to submit required documents listed in 's Corti the Instructions, USCIS or the Department of Sate may deny _1 ceri, under penalty of perjury, that namie Tam fluent in English and ly which isthe same language provided in Part 4, Item Part 5. Interpreter’s Contact Information, Number 1. and have read to this sponsor in th identified ificat Tanguage every question and insiruction on his affidavit and his Certification, and Signature orher 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 acuracy of every answer. Ja. Interpreters Family Name (Last Name) Interpreter's Signature Interpreters Signatur 1b. Interpreters Given Name (First Name) 2. _Interpreter's Business or Organization Name (if any) . alin [Part 6. Contact Information, Statement, Interpreter's Mailing Address [Declaration, and Signature of the Person [Preparing this Affidavit, if Other Than the oe aN Sponsor 3b. Clap. Ose. Orin Provide the following information about the preparer. 3c. City or Town Preparer's Full Name 3d. State Be. ZIP Code Ja. Preparer’ Family Name (Last Name) 3a Province 1b. Preparer's Given Name (First Name) 3g, Postal Code 3h. Country 2. Preparer's Business or Organization Name (if any) Interpreter's Contact Information Preparer's Mailing Address 4. Interpreters Daytime Telephone Number 3.a, Street Number and Name 3b. Clap. Ost. Orie 3. City or Town ‘5. Interpreters Mobile Telephone Number (if any) 6 Interpreters Email Address (ifany) ano ee 346 Province 3g. Postal Code 3h. Country Form F134 0213/19 Page 6 0f8|\Part 6. Contact Information, Statement, [Dectaration, and Signature of the Person [Preparing this Affidavit, if Other Than the [Sponsor (continued) Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Prepare?’s Email Address (ifany) Preparer's Statement 11a. [] 1am not an attomey or accredited representative but have prepared this affidavit on behalf ofthe sponsor and with the sponsor's consent. 7. [] lam an attorney or accredited representative and my representation of the sponsor in this ease Ci extends. [] does not extend beyond the reparation ofthis affidavit NOTE: Ifyou are an attomey or acredited representative whose representation extends beyond preparation ofthis affidavit, you may be obliged to submit a completed Form G-28, Notice of Entry of ‘Appearance as Attomey of Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that | prepared this affidavit at the request ofthe sponsor. The sponsor then reviewed this completed affidavit and informed me that he or she understands all of the information contained in, and ‘submitted wit, his or her affidavit, including the Sponsor's Certification, and that all of this information is complete, true, and correct. | completed this affidavit based only on information that the sponsor provided to me or authorized me to obtain or use. Preparer's Signature S.a, Prepare’ Signature bb. Date of Signature (mm/ddiyyyy) Form F134 02/13/19 Page 7 of8[Part 7. Additional Information Ifyou need extra space to provide any additional information within this affidavit, use the space below. If you need more space than what is provided, you may make copies ofthis page ‘to complete and file with this affidavit or atach 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 Ja. Family Name [Seaca (Last Name) DOES Sa, 54. Number S.b. Part Number 5.c. Item Number ri 1b. Given Name [Gregory (First Name) Le. Middle Name fray 2, A-Number (if any) 6a. Number 6.b. Part Number 6.e. Item Number mA 3. Part Number 3.e, Item Number 6a. 3a, Page Number 4 3 38 34. 1 intend to help Emmanuel find a placo to live and get him a job. If he is ally unabl ‘afford his rent, school tuition, or supplies I will support him financially in order to cover these costs. 1. Page Number 7. PartNumber 7.e. Item Number 4a, Page Number 4.b. Part Number 4e. Item Number 14. 4a. Form F134 0213719