Affidavit of Support Under Section 2134 of the INA Department of Homeland Security US. Chizenship and Immigration Services users Form 1-864 ‘Affidavit of Support Sabmiter or | © Petonsr OMe oo seis | 2 tat Join Sponsor Ferrets Use| 2nd ie Spoor ae Only |G Subsiaue Sponsor ome 12 S94 Ownee Date (aly ‘amber of Sport AMTaavis in File or a2 Tiamat S| Sect ais boi “Toe compleed by an] [) Sekt the box stormy o aceredted| ‘itappeabe) ‘Attorney State Bar Number Attorney or Accredited Representative USCIS Online Account Number (9) [representative (fary.| 281 attache (Port Basis For Filing Attdavit of Support] ube sponsor subeiting ths aid aT suppor bara (Selec any one bo) fa Ty Lent pene | lca ig rte {filed an alin worker ptiion on bao the ® Mailing Address 2a, InCare OFName 2b, Stee Number se 0 Fe ae Dan fe 2a. Civ or Town ae. sate] 26 Pca te, C1 Kean ouprtip se of espe o e 2g. Province [vita conzaLee ARI Tacs worerpeOOTTORITOTIS 24, Pal Cole [fnvinco inant lane eed ea 14. Bl Lambe ot gor ta, C1 tame [1 tet [] mcondotive jie poner: Other Information Lt Tectsnpetoneris deed am he Qo substitute sponsor. 1 am the intending immigrant’s fee NOTE: Ifyeuare ting isfrm saspowor,joumut + DaeofBinh(omddyyy) [07/23/2007 ete rot efgourt Selden US natal, ie pegstae NantetAcNambe am lawl permanent resident status [Par(2. Tnformation About the Principal immigrant USCIS Onine Aczount Number ay) Femi Nene [espras, cum itr ne Given Name (is Name) Mie Nae MULDER ARSAINRES PERERA TRY RE I Destin Telephone Number[Part 3. Information About the Immigrants You] Family Member Are Sponsoring a Family Name (a Name) 1. Tam sponsoring he principal inmigantnanedinPare2. yy, Goer were Yes] No (Applica ony ifyou are sponsoring (retin) family tember in Pct asthe oend 14, Middle Name Jel Sponsor of you ae spontorng {amily meee wo ne mgring 15 Rebtonstp onl niga ‘or than si mon afer the rina ‘migra 2D Iam spoosring te flowing family members 16 Dateof Bin amiddiyy9) immigrating tthe same ime or within si moutsof 47. en Regain Number (ANumbep Gray) ‘he principal igen named in art 2. (Do nt TERE ee areca oa — a Fagan tne pentane (sre) i 4 gen (stam) 16, Mile Name 4s. Miele Name Relationship to rinsgal imine 20, Relonship to Principal migra 6 Date af Binh (mmddyy) 21. DacorBichimmisyyy) = 22, Alle Regitraton Naber (A-Nanben 59) PA 7. Allen Registration Number (A-Namben fan) mA 2A. USCIS Online Account Number amy) iS USCIS Onine Account Number fan) >» Fay Members 24a. Fy Nae 2 | oe 24h, Gergen 9 Ghennane eantes [____ (is Name) Se eeeaeal 25, Relaonship to Peni! Inmigrant 26 Due of ith (nmiseyy9y) 14. Date of Binh (mise) 27. Alle Registration Number A-Namber (any) 12 Alo Registration Naber (A-Nomber ifany) a PA 18, USCIS Ontine Account Number fan) 28 USCIS Online Account Number i a) » iS stn kat URES SES ASA Parzen[Part 3. Inform: Are Sponsoring (continued) = 2. Eater he tll umber of nmi you ae pong on Ins afd whic inlades te principal ipa lies le Part2 an insite n Pat Ie Nambers-= 28 and appl) ay iran sed forthe uctions n Part 1. Adon Information. ‘Sponsor's Physical Address 4a, Sucet Naber Om 0% Om~] he. Cayor Town Mine] «om Soe oe ote toe eee eed 6 Date of Birth (mm/ddiyyyy) [o7/2a/2986 ‘Sponsor's Mailing Address 7% Ciy or Town of ith 2a. InCare Of Name eota = 9. Country of Birth, 2e. Apt C1 ste 0 Pie. [30 focurNicaN REPUBLIC ae = eeeereeeoas &] cose Cece ba de etc ‘Ua. & fam aS. citizen Pry a 3. teyour caren malig addres he une we your pail a Yes [IN you answered "Noto tem Number 3, rove your pial addres in Kem Numbers a = 11. [tam alow permanent resin 12, SponiodsA-Number any) oe 18, Spomods USCIS Online Account Number 9) > Miliary Service (Tobe completed ty peioner sponsors ols) 1M Lam cantly o ative dyn the US. Aemed Forces or US. Cou Gud Ove Be ELIE RARER IRRFor seis Use Part 5. Sponsor's Household Size (OTE: Do ot count any member of your Persons you are sponsoring in thi affidavits 1. Provie the number you entered ia Part, Hem Number ». a Persons NOT sponsored inthis thant 2 Yousef z 3. you are curently marie eter 1" ar your spe 4 Hfyorhave dependent cides, emer the number ee & CRetied Since mmiyyy) 6 Che nemploed sine (mmisy99} s[a3, 963.00 Income you are wing rom any ater person who was ‘hunted in your howschol ing ning. nea ‘Sion, the intending migrant (Soe For 6 Inston) Pleas nse mae, lions, a some, Person SS fyouhae anyother depen enter the number ee 9. Renionship {6 tfyoutave sponsored any other pons on Form 864 Form LEGAEZ who aren lawl permanent rien, OPTIONAL: Ifyou hie tings, pares o alt chien with te Same pri esgene who se binge inom with ours by sbmiting Fm, TH, ener te mame ee . 8. Aadogster Part, tem Nembers umber ere and ent she [Part 6. Sponsor's Employment and Income Tam curently 1. Bi Employed asan 2 Name of Employer 1 3. Nene of Employer 2 apie) 10. Corrent some s| | 13, Curren income s| Person 3 1 Name 1S. Relaionsip 16. Current income s| Person 4 4 Cseicempieyed as aan (Osepation) LMVVIREPR SEES DSTA REEF 1 Retsinsip 18. Current tome s|Tews Sze] Poverty Gustine [Romario fe Jat a2 a3] wseisto. as ge] Yee oi [a7 08 G9) Fomine 3 ot [Part 6. Sponsor's Employment and Income (continued) [Part 7. Use of Assets fo Supplement Income ©ptionsl) 20, My Current Annual Houshold come (Ft all ls fro Par 6 Hem Numbers 7 10 1316, apd 1 he ‘oa wil be compared to Feral Povey Guidelines on Form F864) slegear oo 21, The peopl ised in tem Numbers 8 Hy Hand stave completed Form 861A. 1am ling ions, ith his eave al necessary Foon 864A Completed by these people 22.) Oncor mor ofthe peopl sted in Hem Numbers {IL and 17 dona edt compete For 1A bees he othe the tending int nd accompanying pends, Name Federal Income Tax Return Information 2. Have you fled a Federal inom a etn for ach fhe thre oe ect tn yeas? Baye Cs NOTE: You MUST atach aphsocopy or tensiptof your Feder income art foro the st rset 280.0] (Optional hve atached ptotocopic or raseripte ‘fy ede incor tax turns for my second aed ‘hed oat recent tx years, My ota income aut gros income on Ira Reve Serie (IRS) Form 1MDEZ) ae epred ony Fea some {arene forthe no ecem thee yeas was TexYeur Teal income 2a Most Recent 2023] S{3, 963.00 21, 2nd Most Recent s 2, 31d Most Reset s 25. Oy Lasnot required tle a Feder come ta tan asm income was below he IRS rege eve nd ave atc evidence o apport this tfyour income, rth tlncome fr your and your bosehol ff Part em Nembers20 or 24a, - 240, cess he Fler Povey Guidlines or yor hous sie, VOU ARE. [NOT REQUIRED to compe his Part 7. Skpto Part. » 1. ret bane of al vines and checking acount, 5 Your Assets (Op 2. Enerthe net each vale ofteal-stte oigs (Net ‘ale means urent aesesed vole mins mariage dt) s| ‘A. Enerthenet each ale ofa socks, bons ceiaee ‘of deposi and any ete sets ot already clade io tem Nember fr Hen Number 3, s| 4. Adi ogee tem Nambers here. ‘TOTAL: 5| cand etre ber Assets hom Form 864A, Par 4 lem Nomber 3 Sa, Nae of Relive pense ‘Sb. Your household members ass om Form 164A (eptonad, 7 Assets ofthe pinipal sponsored immigrant opin). “The principal sponsored immigrant is te person tse in Part 2, tem Nombers Lae On ince he ses ihe principal inmigrans being sponsored by ts ait of oppor. 6 Enterte lance of the picpalinmiarnt savings and checking scum : realest ldings (Net alte means ivestment value ‘insmenange ec) | 8 Enverthe caren cash vale ofthe principal inmigars Stocks, bos, ceifeates of depos and ther ss mot Included in Herm Number 6,01 Hes Number s| ENR ERE SRLSourcold Sis Poverty Guideline ‘Sponsors Hovsehol come] Remarks umf 02 03) va Slay os a6 s ony [27 os co] Povenytine 2 other__ | $_ [Part 7. Use of Assets to Supplement Income |(ptiona) (continued) 9. Addtogeber em Nombre 6 8 othe number 10, Ai ogether Hem Numbers 4 5, nd 8. and enter the number her. for 3 eee] [Part 8. Sponsor's Contract, Statement, Contact information, Declaration, Certification, and Signature NOTE: Red ihe Peale section of he Form 864 Instacton bef eampleing ti pa ‘Sponsor's Contract Peete that by saning thi Form 26, yu ge ‘stm cnin specie obligations ude th Inigraton snd Nationality Act (INA) and other Feder ws Th following purasapi desrbe hose obligations. Plas ed te felons ifloration early before you in Fon L464. If yotdo net undestnd the obipions, you nay wish consult the Legal Eet of My Signing Form -86¢2 yu sign Fos 1-64 on bel of any person (alld he atendig migrant) who i plying fr ning visa oe ‘or aajstmet of sso awl permanst eset an hat Intending unaran sebits Form 8640 th US. \Goversent wih hi her apn fran mia vis oe ejusent of sat, under INA seton 2134, thse scons {rete cont between you athe US. Goverment. The intending momar becoming» evil prnen det User his contract you saree tht in dcding whether he Intening isin can eal that eo sh ak. Inndmisbe the Unie Stats a person lily bse & public care, the U.S. Goverment cn coir your income fd antes a ailble rhe support oh nding ‘What IT Choose Noto Sign Form E864? The US. Government cannot make you sign Form I-86 you ove want to do so. But yo cd ot sign Form 36, he intending npn may not Become al prmane resident inthe Unie Sates, ‘What Does Signing Form L864 Requte Me To Do? Ian intending migrant becomes vel prmanent eink inthe United States sed ona Form F364 you hve ‘gnd hen until your bligations uncer For 864 ein, [AL Provide the intending ineirat ay support. cesar to mat en ot her ta neo that i eat 25 percent of he Federal Poverty Guieines Tori or her household size (100 pen i you re the ptonng sponsor and ze o eve Sty inthe US. Armed Fore or US. Cost Guid an he son your husband, wil, cuore hls Ader Jem of gs od ‘atify US, Citizenship and tmigrtion Services (USctS) ofan change in you aes, within 30 Saysof he change, by fling For L868, ‘What Other Consequences Are There? I ictendngnuigrant becomes lawl peomnent resent inthe Utd tater bared ons For 1-86 tha you Rave ‘and then, oni your sigan nde Form E64 ering ‘HeUS. Goverment may conser (deem) yorincame and ‘Sie a avaible ht pron determining wht he ot She gible for ean Federal means-tested publi beets {nao fr sate or oc meanstested publ beefs, he ato ea goverment rls provide for onion (Gesing of your income and atts a valle oth person. This provision does mot apply to public bene pees section D3 ofthe Welfare Reform Act cha emerge esis, shortsern non-eash emergent et series rovied uncer the Nationa School Lanch and Cid Nain ‘Res immaninsions and tering and etre ommomiabl dieser, nd meee prota under the Elementary and Secondary Edveaton Act. ‘Wha 11 Do Not Ful My Obligation you do not provide scent support tothe peso who eomes al permanent resident based on Fon L864 "hn yo signed ht person ays ou fr th upper. DRE NE PRES PDLSR RP[Part 8. Sponsor's Contract, Statement, Contact ‘Information, Declaration, Certification, and [Signature (continued) Ifa Feral ste, oslo pvt apeney provided any covered eases pubic benefit tothe pron wh Besane nfl Permanent resien based on Fax 868 tat you sie, the geey may ask you to veimburse thm fr the acto the tenets they provided. Ifyou do nat make he reimbursement, the agency ay sue Yu fe he amount tat he apency Beleves you rsd and he cour eters judgment agin you the enon orageny tat ed yu ay tte ny ely pred rosedue or enforcing o colle the judgment. You ay 1 be reared pay the cota election ming yeu do ot lea propery completed Form L865 witin 30 says of any change fares, USCIS may nose a ie for your ing doo, 2 Will These Obligations End? Your obligations under Form -864 ht ou signed wil end ‘epson who becomes lawl permanent een based 08 that oi AL Becomes US. item Hiss worked or en esve xe fo, 40quars of (G_Notongeras lawful permanent resident satus and ns departed the United Sates D._ Is subject removal, ut plies fan bis, removal proceeding, new gan of adjustment of Sts, based on anew adit of spt ones Eis, NOTE: Divore does nt terminate you oligaions wer Form 64 Your obligations under Form I-64 tht you signed als nd it youdle. Therefre you de, youre ent ous 2 {ake responsi faethe persons suppor your death However your ext may owe ay spp tha ou semua before ou did ‘Sponsor's Statement NOTE: Sees he box foster em Number Lao Mh applicable, sles be box fr Hem Number 2. 1D teanread and understand English and ve read nd uses every uestion ad issn on hi ‘idvicand my answer ta evry question 1b. [Th htepeter xed io Part 9 read tome vey Taagage WEN Tw TET, wT URORT veoh Any request the preparer nein Pat 0, reps i aida Tor SES wpa {nfomation I provided or ahora. ‘Sponsor's Contact Information 3 Snso?’s Daytine Telephone Number [sera6ea767 44 Sponsors Mobile Telephone Number fam) [sa73643767 S.Sponars Ena Ades Ga) [ruenarsenvanzs0«e@a. cox ‘Sponsor's Declaration and Certification Copies of any documents ave submited are exet poops of tlre, cgi docuents, a wndensand fat USCIS oe the US. Deparmet of State (D0S) a9 rege ‘ha sabi gina documents to USCIS r DOS as er fe, Furthermore, authorize the reese of an information fom any ad alo my cr tht USCIS oF DOS may nee to line my lily forthe net tt sek “chermore authorize eet of nfo onan ia this affidavit in supporting documents, and my USCIS or DOS. ‘scr, oir ents and persons where mesa forthe ‘insraton and enforcement oF US. imran 1 cei, under penaly of ery that al ofthe infomation in ‘yada and ay document submit with were rosie {raubornd by me, that reviewed and understand al of te Information contained nan sated with my aff nd tal ths information complete, te, and cet, A. Lh th contents of hi aa of spp that slened B. I hwvereadand I understand cash of th abligaons scribed it Part an ase, fel and without lary mental servation of purpose af asian scept cach of hose obations in orcerto make it esse forthe immigrated in Pat 3.10 corel permanent eden fhe Unto Lect submit the personal juin of any ode or sate court ht haw subject mater, justo of await agaist me 6 enforce my ‘lions under is Form 88 AMINES PREPARA I[FBFC8. Sponsors Contract Statement, Contact| Information, Declaration, Certification, and Interpreter's Mailing Address [Signature (continued) - nee . Essh fhe Federal some wets bed fate eee suppor of this ffidi are te opts, rae oe eo ‘aed rans of he a ete led oe se, ee Landers tat ifLam ete othe sponsored BS Se. ZIP Code ‘nvr by mariage, he emotion othe : inainge (by ivorce,dsluten, antes ot tthe el process) wll note mea) hin under his Fo 864 and FL authorize the Sci Security Adminitaion 1 reese information abut mein reser ‘Sponsor's Signature 6b DavotSignaure (mmddyy) [85/25/2008 out this ala ao sub eid documents sted ‘heaters, USCIS or DOS may deny yor dei, [Part 9. Tnterpreter's Contact Information, \Certification, and Provide the flowing information about the inert Interprete's Full Name a, merece Family Name (LastName) 1 lntrpeters Given Name it Nae) 2 nets Busines or Organization Name fay) MULDER ES PS SPEEA IEP Bl Sg. Posi Code Sh. County Interpretr's Contact Information 4. Inetes Dayne Telephone Number 5. Ineretes Mobile Telephone Number 59) 6 trp Email Ades any Interpreter's Certification eri nde pen of xy ta: Iam fentn Enelih and ‘which the same Inguage peed a Fa Tem Naber 1. and have rato his sponsor inthe etd angage rey gusto andinstucton on thi aig andi oer Sree every querion. The onornfermed me that e She unas every nseton, question al answer on he tiv including the Sponsor's Declaration ana ‘Cetin. an has verified he ceray of every answer. Interpreter's Signature “a. Inept Signe 1am Davo Signature miyyyy)formation, Declaration, and Signature ofthe Person Preparing this Affidavit, if Other Than the Sponsor Provide the following inormation about te propre Preparer's Full Name a Prope’ Family Name (Lae Name) ‘Lb, Peepers Given Name (Fs Name) 2 a Busines or Orpaniztion Name fan) Proparer's Mailing Address 3a. SuestNunber [551 yeay Tee SET So Clam C1 se. Bre fe «id 2 be 3d. Suef] 34. ziPcote[x0033 1 | 3h County ‘Preparer's Statement ‘ia, lam not anatomy or acrid representative bat ave prepared this affiavit on Bea ofthe sponsor tnd with he sponsor's conse. ‘iy. Cy Lam anatorey oe credited epresenative nd my reprsesition ofthe sponsor in thi cae (Chests) doesnt extn beyond the FPeprtion of his tai NOTE: Ifyc ate an aoe or acrid ‘eyes you may be obliged to sbi ampleed Foe 6-28, Nac of Ey of AAppedrnce se Aten or Accredited Representative, or 2M, Noe of Ext of (Caras! Cones of te United Stes, with his sid Preparer's Cerification By my sgt, cert, ne ely of py, at prepa hs alii the regs ofthe sponse. The Sponsor he eviewed his competed david informed ‘teat be ose ude of th formation coined Ian stb vhs ore aiden te Sponors Declaration nd Certifeaton, an that al ofthis information compl, empl his eorandonsde coum cr te Pry Sate sn. (Prepares Signore Preparer's Contact Information 4. Prpurers Dayne Telephone Number 5 ae Telephone Number Fy) (6 Pape Ema Ades Gita) (MULDER RESPU CRSA Fa Rb. Date of Sige wi [oares/20ze[Pare 11 ‘Additional Information Sa, Page Number Si, Pat Number Stem Number provide ny aoa foaton tl Ir you need ext pet provide ay adil intrnaion wih this aia se the spac etw. Myouneed more Sa Space than whats provided, oumay make cops a ts page {@eomplee and file with hs ada oath sept see. ‘ot paper Type ope your ue and A Number any) athe topo each set indeat the Page Number, Part Nember, {nd tem Number o which you ssher reer ania and fe each set, (tt Name) Eh Given Name [Ee (eis Name) BEER 2 ANmber any) mA Sa, FageNumber 3b. PutNunber Se lem Number Ga, PageNumber 6b, PutNumber Ge. ten Number aa oa. 4a, Page Number 4b, Pat Number elem Number Ta, psy Pat Namber 7, tem Number 4a 1. Fort eon 10881 INE DADS PER Tne rt9