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I-134 Submission One 1-6

The document provides information about an individual who is financially supporting a beneficiary, detailing their employment status as a nurse at Homeward Bound Inc. It includes the employer's address in Plymouth, MN, and outlines the individual's income and dependents, listing two sons with a total annual income of $6,000. Additional financial information can be provided in a separate section if needed.

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13 views1 page

I-134 Submission One 1-6

The document provides information about an individual who is financially supporting a beneficiary, detailing their employment status as a nurse at Homeward Bound Inc. It includes the employer's address in Plymouth, MN, and outlines the individual's income and dependents, listing two sons with a total annual income of $6,000. Additional financial information can be provided in a separate section if needed.

Uploaded by

kenanieric160
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Part 3.

Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)

Employment Information
11. Employment Status
✔ Employed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed Retired

Other (Explain):

If you indicated that you are employed in Item Number 11., provide the information requested in Item Numbers 12. - 13.

12. A. ✔ I am currently employed as a/an Name of Employer


Nurse Homeward Bound Inc

B. I am currently self-employed as a/an

13. Current Employer's Address


Street Number and Name Apt. Ste. Flr. Number
12805 HWY55 ✔ 400
City or Town State ZIP Code
PLYMOUTH MN 55441
Province Postal Code Country
US

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.

Full Name Date of Birth Relationship to the Individual Agreeing Income


(First, Middle, Last) (do not include any (mm/dd/yyyy) to Financially Support (Type or print Contribution to the
individuals named in Part 2.) “Self” for Individual Agreeing to Beneficiary
Annually (if none,
Financially Support the Beneficiary)
type or print $0)
Evan Gisore 10/28/2017 son $ 3,000
Emmanuel Ogoti 07/26/2021 son $ 3,000
$
$
$
Total Number of Dependents 2
Total Income $ 6,000

Form I-134 Edition 11/09/23 Page 6 of 13

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