Online Request to be a Supporter and

Declaration of Financial Support

USCIS
Department of Homeland Security Form I-134A
U.S. Citizenship and Immigration Services

► START HERE - Type or print in black ink.

Part 1. Basis for Filing

1. I am filing this form on behalf of: Myself as the beneficiary. Another individual who is the beneficiary.

2. I am filing this form under one of the following:

4.
SAMPLE
If "Parole Process" selected in Item Number 2.

3. I am filing for an individual under the parole process for the following country

If "Family Reunification Program" selected in Item Number 2.

I am filing for my relative who is associated with an approved I-130 and a national of:

5. Invitation Number:

6. How many total family members will be included in this family reunification group
who all share the same invitation number?

DO NOT
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.)
Family Name (Last Name) Given Name (First Name) Middle Name

2. Other Names Used

SUBMIT
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.
Family Name (Last Name) Given Name (First Name) Middle Name

3. If "Family Reunification Program" selected in Part 1., Item Number 2. Is this the individual listed as the Yes No
principal beneficiary in your Family Reunification Parole Process invitation letter?
4. A grant of parole is a discretionary determination granted on a case-by-case basis for urgent humanitarian reasons or significant
public benefit. Please explain why a favorable exercise of discretion is merited for this individual.

5. Date of Birth (mm/dd/yyyy) 6. Sex 7. Alien Registration Number (A-Number)

M F X ► A-

Form I-134A Edition 07/11/23 Page 1 of 14

Part 2. Information about the Beneficiary (continued)
8. Place of Birth
City or Town State or Province

Country

9. Country of Citizenship or Nationality

10.

11.
SAMPLE
Passport Number of the beneficiary's most recently issued passport Country that issued the most recently issued passport

Expiration date for the most recently issued passport (mm/dd/yyyy)

Marital Status
Single, Never Married Married Divorced Widowed Legally Separated Marriage Annulled

Other (Explain):

12. Beneficiary's Mailing Address

In Care Of Name

DO NOT
Street Number and Name Apt.Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

13.

SUBMIT
Are the beneficiary's mailing address and physical address the same?
If you answered “No” to Item Number 13., provide your physical address in Item Number 14.
14. Beneficiary's Physical Address
In Care Of Name
Yes No

Street Number and Name (Do not provide a PO Box in this space unless it is your ONLY address.) Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

15. Beneficiary's Daytime Telephone Number 16. Beneficiary's Mobile Telephone Number (if any)

17. Beneficiary's Email Address (if any)

Form I-134A Edition 07/11/23 Page 2 of 14

Part 2. Information about the Beneficiary (continued)

Beneficiary's Anticipated Length of Stay

18. Beneficiary's Anticipated Period of Stay in the United States

From (mm/dd/yyyy)

To (select one):

(mm/dd/yyyy)

No End Date

SAMPLE
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
19. 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 24. and not in Item Number 19.

DO NOT
Individual's Full Name Date of Birth Relationship to the Beneficiary
Income contribution
(First, Middle, Last) (do not include any (mm/dd/yyyy) (Type or print “Self” if you are filing for
to the beneficiary
individuals named in Part 3.) yourself as the beneficiary or
annually (if none,
“Beneficiary” if someone is agreeing to
type or print $0)
support you in Part 3.)

SUBMIT Total Number of Dependents

$

Total Income $

20. Does any of the beneficiary's total income (including income from dependents and other Yes No
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)?
21. If you answered “Yes” to Item Number 20., what amount of the beneficiary's total income comes $
from an illegal activity or source? (Type or print “N/A” if you answered “No” to Item Number 20.)
22. Does any of the beneficiary's total income come from means-tested public benefits as defined in Yes No
8 CFR 213a.1?
23. If you answered “Yes” to Item Number 22., what amount of the beneficiary's total income $
comes from means-tested public benefits?

Form I-134A Edition 07/11/23 Page 3 of 14

Part 2. Information about the Beneficiary (continued)
Beneficiary's Assets
24. 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.

Full Name of Asset Holder Type of Asset Amount (Cash Value)

(First, Middle, Last) (U.S. dollars)

SAMPLE
TOTAL (U.S. dollars) $

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in

DO NOT
Part 2.
If you are not the beneficiary named in Part 2., complete Part 3.
1. Current Legal Name (Do not provide a nickname.)
Family Name (Last Name) Given Name (First Name) Middle Name

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.

SUBMIT
Family Name (Last Name) Given Name (First Name) Middle Name

3. If "Parole Process" selected in Part 1., Item Number 2. Provide the name of the organization, group, or individual that is
providing support to the beneficiary with you (if any)
Organization, Group, Individual Name

4. If "Family Reunification Program" selected in Part 1., Item Number 2. Provide the name of the individual(s) or co-sponsor(s)
that is providing support to the beneficiary with you (if any).
Individual(s) or Co-sponsor(s) Name

Form I-134A Edition 07/11/23 Page 4 of 14

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)
5. Current Mailing Address
In Care Of Name

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

6.
Province
SAMPLE Postal Code Country

Is your current mailing address the same as your current physical address? Yes No
If you answered “No” to Item Number 6., provide your current physical address in Item Number 7.
7. Physical Address
In Care Of Name

City or Town
DO NOT
Street Number and Name Apt. Ste. Flr. Number

State ZIP Code

Province Postal Code Country

Other Information
8.

10. Place of Birth

City or Town
SUBMIT
Date of Birth (mm/dd/yyyy) 9. Sex

State or Province
M F X

Country

11. Alien Registration Number (A-Number) 12. USCIS Online Account Number
► A- ►

13. Social Security Number 14. What is your relationship to the beneficiary?
►

Form I-134A Edition 07/11/23 Page 5 of 14

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)

Immigration Status
15. What is your current immigration status? Provide documentation as provided in the instructions.
U.S. Citizen
U.S. National
Lawful Permanent Resident
Nonimmigrant Form I-94 Arrival-Departure Record Number

Other (Explain):

Employment Information
SAMPLE
►

16. Employment Status

Employed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed Retired

DO NOT
Other (Explain):

If you indicated that you are employed in Item Number 16., provide the information requested in Item Numbers 17. - 18.

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

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

18. Current Employer's Address

Street Number and Name Apt. Ste. Flr. Number

City or Town

Province
SUBMIT Postal Code Country
State ZIP Code

Form I-134A Edition 07/11/23 Page 6 of 14

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)

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
19. 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 24. and not in Item Number 19.

SAMPLE
Full Name
(First, Middle, Last) (do not include any
individuals named in Part 2.)
Date of Birth Relationship to the Individual Agreeing
(mm/dd/yyyy)
“Self” for Individual Agreeing to
Financially Support the Beneficiary)
Income
to Financially Support (Type or print Contribution to the
Beneficiary
Annually (if none,
type or print $0)
$
$
$
$

20.
DO NOT Total Number of Dependents
Total Income $
Does any of the income listed above come from an illegal activity or source (such as proceeds from
$

Yes No
illegal gambling or illegal drug sales)?
21. If you answered “Yes” to Item Number 20., what amount of income comes from an illegal activity? $
(Type or print “N/A” if you answered “No” to Item Number 20.)
22. Does any of the income listed above come from means-tested public benefits as defined in 8 CFR Yes No
213a.1?
23.

Assets
24.
public benefits?
SUBMIT
If you answered “Yes” to Item Number 22., what amount of income is from means-tested $

Fill out the table below regarding the assets available to you (do not include any assets from any individuals named in Part 2.).
Attach evidence showing you have these assets.

Full Name of Asset Holder Type of Asset Amount (Cash Value)

(you or your household member) (U.S. dollars)

TOTAL (U.S. dollars) $

Form I-134A Edition 07/11/23 Page 7 of 14

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)

Financial Responsibility for Other Beneficiaries

25. Have you previously submitted a Form I-134A on behalf of a person other than the beneficiary Yes No
named in Part 2?
If you answered “Yes” to Item Number 25., provide the information requested in Item Numbers 26. - 27. If you need additional
space to complete this section, use the space provided in Part 8. Additional Information.
26. Person 1

SAMPLE
Family Name (Last Name) Given Name (First Name) Middle Name

A-Number Date Submitted (mm/dd/yyyy)

► A-

27. Person 2
Family Name (Last Name) Given Name (First Name) Middle Name

A-Number Date Submitted (mm/dd/yyyy)

28.
► A-

DO NOT
Intent to Provide Specific Contributions to the Beneficiary
You are responsible for receiving, maintaining, and supporting the beneficiary for the duration of their temporary stay in the
United States. Describe the resources you plan to use or provide to ensure the beneficiary has adequate financial support to
cover their basic living needs.

29.
SUBMIT
You are responsible for ensuring that the beneficiary has safe and appropriate housing for the duration of their parole in the
United States. Describe how you will ensure that the beneficiary's housing needs are met, including where the beneficiary will
reside during their temporary stay in the United States, if known.

Form I-134A Edition 07/11/23 Page 8 of 14

Part 3. Information About the Individual Agreeing to Financially Support the Beneficiary Named in
Part 2. (continued)
30. You are responsible for assisting the beneficiary's access to available services and benefits such as learning English, securing
employment opportunities once authorized to work, enrolling children in school, and helping to enroll for benefits for which
they are eligible. Describe what steps you plan to take as part of these responsibilities.

SAMPLE
Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (Only complete
this section if Part 1. Basis for Filing selection is "Myself as the beneficiary", otherwise continued to Part 5.)

If you are the beneficiary and are filing Form I-134A on your own behalf, complete and sign Part 4.
NOTE: Read the Penalties section of the Form I-134A Instructions before completing this section.

DO NOT
Beneficiary's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1. I, as the beneficiary, certify the following:
A. 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.
B. 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 understood
everything.

2. At my request, the preparer named in Part 7., , prepared

SUBMIT
this declaration for me based only upon information I provided or authorized.

Beneficiary's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS or the
Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Furthermore, I
authorize the release of any information from any and all of my records that USCIS or the Department of State may need to determine
my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this declaration, in supporting documents, and in my USCIS or the Department
of State records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
I 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 I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my declaration;
2) I understood all of the information contained in, and submitted with, my declaration; and
3) All of this information was complete, true, and correct at the time of filing.

Form I-134A Edition 07/11/23 Page 9 of 14

Part 4. Statement, Contact Information, Certification, and Signature of the Beneficiary (Only complete
this section if Part 1. Basis for Filing selection is "Myself as the beneficiary", otherwise continued to Part
5.) (continued)
I certify, under penalty of perjury, that I provided or authorized all of the information in my declaration, I understand all of the
information contained in, and submitted with, my declaration, and that all of this information is complete, true, and correct.
That this declaration is made by me to assure the U.S. Government that I will be able to financially support myself while in the United
States.
That I am willing and able to pay for necessary expenses for the duration of my temporary stay in the United States.

Beneficiary's Signature
3.

SAMPLE
Beneficiary's Signature

Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to
Date of Signature (mm/dd/yyyy)

Financially Support the Beneficiary

If you are filing Form I-134A on behalf of someone else (the beneficiary listed in Part 2.), complete and sign Part 5.
NOTE: Read the Penalties section of the Form I-134A Instructions before completing this section.

1.
DO NOT
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.
I, as the individual agreeing to financially support the beneficiary, certify the following:
A. 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.
B. 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 understood.

2. At my request, the preparer named in Part 7., , prepared this

3.
SUBMIT
declaration for me based only upon information I provided or authorized.

Contact Information of Individual Agreeing to Financially Support the Beneficiary

Daytime Telephone Number 4. Mobile Telephone Number (if any)

5. Email Address (if any)

Certification of Individual Agreeing to Financially Support the Beneficiary

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS or the
Department of State may require that I submit original documents to USCIS or the Department of State at a later date. Furthermore, I
authorize the release of any information from any and all of my records that USCIS or the Department of State may need to determine
my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this declaration, in supporting documents, and in my USCIS or the Department
of State records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

Form I-134A Edition 07/11/23 Page 10 of 14

Part 5. Statement, Contact Information, Certification, and Signature of the Individual Agreeing to
Financially Support the Beneficiary (continued)
I 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 I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my declaration;
2) I understood all of the information contained in, and submitted with, my declaration; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury, that I provided or authorized all of the information in my declaration, I understand all of the
information contained in, and submitted with, my declaration, and that all of this information is complete, true, and correct.

SAMPLE
That this declaration is made by me to assure the U.S. Government that the person named in Part 2. will be financially supported
while in the United States.
That I am willing and able to receive, maintain, and support the person named in Part 2. to better ensure that such persons will have
sufficient financial resources or financial support to pay for necessary expenses for the period of his or her temporary stay in the
United States.
I acknowledge that I have read this section, and I am aware of my responsibilities as an individual agreeing to financially support the
beneficiary.

Signature of Individual Agreeing to Financially Support the Beneficiary

6. Signature

DO NOT
NOTE TO ALL INDIVIDUALS AGREEING TO FINANCIALLY SUPPORT THE BENEFICIARY: If you do not completely
Date of Signature (mm/dd/yyyy)

fill out this declaration or if you fail to submit required documents listed in the Instructions, USCIS or the Department of State may
deny or not consider your declaration.

Part 6. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.

2.
SUBMIT
Interpreter's Family Name (Last Name)

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Mailing Address

3. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Form I-134A Edition 07/11/23 Page 11 of 14

Part 6. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any)

6. Interpreter's Email Address (if any)

Interpreter's Certification

SAMPLE
I certify, under penalty of perjury, that:

I am fluent in English and which 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.

Interpreter's Signature

DO NOT
7. Interpreter's Signature Date of Signature (mm/dd/yyyy)

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. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)

2.
SUBMIT
Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Form I-134A Edition 07/11/23 Page 12 of 14

Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Declaration, if
Other Than the Individual Agreeing to Financially Support the Beneficiary (continued)

Preparer's Contact Information

4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number

6. Preparer's Email Address (if any)

Preparer's Statement
7. A.

B.
SAMPLE
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.
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 does not extend
beyond the preparation of this declaration.

NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this application.

Preparer's Certification
DO NOT
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.

SUBMIT
Preparer's Signature Date of Signature (mm/dd/yyyy)

Form I-134A Edition 07/11/23 Page 13 of 14

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.
1. Family Name (Last Name) Given Name (First Name) Middle Name

2. A-Number ► A-

SAMPLE
3. A. Page Number B. Part Number C. Item Number

D.

DO NOT
4. A. Page Number B. Part Number C. Item Number

D.

5. A. Page Number B. Part Number C. Item Number

D.
SUBMIT
6. A. Page Number B. Part Number C. Item Number

D.

Form I-134A Edition 07/11/23 Page 14 of 14