3 4 5 9  Lawrenceville - Suwanee  Rd., Suite A,  Suwanee ,  Georgia

Tel: (770) 271-5244 ● Toll Free:  (888) 768-7252 ● Fax: (770) 271-5604 ● Cornel@PotraLawFirm.com ● www.potralawfirm.com

Attorneys:  Cornel Potra – Admitted: Georgia & Washington  ●  Kristina F Potra – Admitted: Georgia

This questionnaire is for the exclusive use of Potra Law Firm.  Please answer all the questions.  Do not leave any questions unanswered.  If you do not have an answer to a question, please insert “N/A”.  It is your responsibility to provide true and accurate information, as well as the evidentiary documents requested. 

This Document Is For The Attorney’s Office Use Only

 

  

QUESTIONNAIRE FOR THE I-134 AFFIDAVIT OF SUPPORT

 

 

Personal Information

 

1. Full Name

a. Family name

 b. First name

c. Middle name

 
 

2. Current address

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

   e. Country

 

 
 
 

3. Date of Birth month/day/year

 

4. Place of birth City/State/Country

 

 

 

5. Select one of the following:                                                     

 

a.

     
 

b.

give the naturalization certificate number

 

c.

 

 
 

d.

give the Alien number (A#)

 

 

 

6. Age

7. Date you started residing in the U.S. month/day/year

 

8.   Information about the person you are filing for

 

    Full Name

a. Family name

 b. First name

c. Middle name

 

 

d. Gender

e. Age

f. Country of citizenship

g. Marital status
h. Relationship to you

i. Address

   Street  number

   City

   State/Province

   Zip code

   Country

 

 
 

 

9. Information about the spouse and children accompanying or following to join the person you are filing for:

 

A. a. Family Name
b. First Name
c. Middle Name
d. Gender
e. Age
f. Relationship to the sponsored immigrant
   

 

B. a. Family Name
b. First Name
c. Middle Name
d. Gender
e. Age
f. Relationship to the sponsored immigrant
   

 

 

C. a. Family Name
b. First Name
c. Middle Name
d. Gender
e. Age
f. Relationship to the sponsored immigrant
   

 

D. a. Family Name
b. First Name
c. Middle Name
d. Gender
e. Age
f. Relationship to the sponsored immigrant
   

 

E. a. Family Name
b. First Name
c. Middle Name
d. Gender
e. Age
f. Relationship to the sponsored immigrant
   

 

For additional family members, use the space below.

It is very important that you respect the order of the information requested.

 

 

10. Current employment

 

a. Type of business

b. Name of company

c. Address of the employer

  
    Street number

    Suite number

    City

    State

    Zip Code

    Country

d. Job title (occupation)

 

 

 

Please indicate

 

11. Your individual annual income

12. The total of all savings accounts

13. The total value of  other personal property

 

14. The total value of all  the stocks and bonds

15. The amount of the life insurance

16. The cash surrender value of the life insurance

17. The value of the real estate

18. The amount that you still owe in mortgage

 

 

19. Give the address of your real estate

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

   e. Country

 

 
 

 

20. List ALL the individuals that are dependent upon you for support

 

A. a. Family Name
b. First Name
c. Middle Name
d. Age
e. Relationship to you
f. Select one of the following
   

 

 

B. a. Family Name
b. First Name
c. Middle Name
d. Age
e. Relationship to you
f. Select one of the following
   

 

 

C. a. Family Name
b. First Name
c. Middle Name
d. Age
e. Relationship to you
f. Select one of the following
   

 

 

D. a. Family Name
b. First Name
c. Middle Name
d. Age
e. Relationship to you
f. Select one of the following
   

 

 

E. a. Family Name
b. First Name
c. Middle Name
d. Age
e. Relationship to you
f. Select one of the following
   

 

For additional dependents, use the space below.

It is very important that you respect the order of the information requested.

 

21. Have you previously submitted affidavit of support for any other person?

If yes, give the following:

a. Name of the person you filed for

b. Date of filing month/day/year

 

  
 

22. Have you ever submitted visa petition to the Bureau of Citizenship and Immigration Services for any other person?  

     

      If yes, give the following:

a. Name of the person you filed for

 

b. Relationship between you and the person you filed for

 

c. Date of filing  month/day/year

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: THIS DOCUMENT IS THE PRODUCT OF POTRA LAW FIRM. THE USE OF THIS QUESTIONNAIRE BY OTHER INDIVIDUALS OR LAW FIRMS IN ASSISTING OTHERS WITH THE COMPLETION OF DOCUMENTS, OR FOR ANY OTHER PURPOSES, IS STRICTLY PROHIBITED.   POTRA LAW FIRM MAINTAINS ITS COPYRIGHTS OVER THE TRANSLATION OF THIS DOCUMENT.  PERMISSION TO USE THIS DOCUMENT MAY BE OBTAINED ONLY FROM POTRA LAW FIRM.  COPYRIGHT © January 17, 2007.