Hospital Pharmacy Pennsylvania Hospital

7. I am employed as or engaged in the business of with

(Type ofBusiness) (Nanie of Concern)

. 800 Spruce SLreet PA 19107

at
(Street Nunrber and Name (City) (Stlte) (Zip Code)

I derive an anrrual income of:. (lf self-enployed, I hat:e attached a copy of ttty last incotne tctx retunr or
report of'atmrnercial rating concern wh.ich I certify kt he h'ue and con'ect ta tlte best of my hnu,ledge
42,000.00
and belief. See instntctions.for nature of s;idence of net u'orlh ttt he suhnitted.) $

{ 32,658 .52
I have on deposit in savings banks in the United States:

I have other personal property, the reasonable value ofwhich is: $

I have stocks and bonds with the following market value, as hdicated on the attached list, which I certif,-
to be true al,d correct to the best of my knowledge and beliel': $
140,000.00
I have life insurance in the surn of: $

With a cash sulrender value of': $

42,000.00
I own real estate valued at: $
0.00
With mortgage(s) or other encumbrarrce(s) thereon amounting to: S
? 7 anv'i nnf
^ri
P.l I lnr\o r f)^ rhrt PA 19082 -_
Which is located
(Street Nunrber and Name) (City) (State) (Zip Code)

8. The follorving persons are dependent upon me for support: (Check the box in tlre appropriate oolunln to indicate whether the person nanred is
wholly or partial/y dependent upon you for support.)
Name of Person Wholly Dependent Parlially Dependent Age Relationshio to Me
none tr n
n n
n n
9. I have previously subnritted affidavit(s) ofsupport for the following person(s), lf none, state "None".
Name of Person Date submitted
None

10. I have submitted a visapetition(s) to U.S. Citizenship and Immigration Services on behalf of the I'ollowing person(s). If none, state "None".
Narne of Person Date subnritted
None

ll. I [l intela I Oo not intend to make specific contributions to the support of the person(s) lamed in item 3.

(If},oucheck',intend,,,indic4tetl'ee!actnatureandduration'ofthecontributions.Fore.rample,ifyouintendto.futltish
in U.S. dollars and whether it is to he given in a lttmp sum,
how long and, if'tnone-v, state the amounl
NOTARIAL SEAL

bs 3Si My Commission fxpires Sep 25, 2016

Oath or Affirmation of Sponsor

lJ€'c@
l acknowledge that I have read "Sponsor and Alien Liabili{'rr on Page 2 of the instructions for this
responsibilities as a sponsor uneler the Social Security Act as amentled, and the Food Stamp Act,
#Trn"
Hoar'rg Le

l certify under penalty ofperjury under United States law that l,kqow the contents ofthis affidavit signed by nte and that the statement$ are
true and correct. )"*
Signature ofSponsor Date 09/10/1s

FormI-134 A2l19lI4 Y Paee2

 OMB No. l6t5-00i4; Expires 02129/2A16
Department of Homeland Security
U.S. Citizenship and Inmigration Services Form I-134, Affidavit of Support

(Ansn er all items. Type or print in black ink.)

I" Aiden Hoang Le '/101 Hazel Ave
residing at
(Name) (Street Nuntber arrd Name)
Upper Darby PA I 9082 United St.ates of Ameri.ca
(Cily) (Siate) tZ.ip C*t. liit t-l.S,l' (Country)
certify under penalty of perjury under U.S. law, that:
ub/uv/ rY t |
06/AB/Igi1 Ri:
'n Ba Ria Vung Tau
l. I was born on Vietnam
(Date [mm/dd4ryyJl (Clity) (State) (Country)
lf you are not a u S. citizen based on your birth in tlre united States, or a non-citizen U.S. national basecl on your birth in American Samoa (includirrg
Swains lsland), auswer the following as appropriate:

a. If a u.s.citizen through naturalization, give cer.tificate of Naruralization number A02525181 9

b. If a U,S. citizen through parent(s) or marriage, give Certificate of Citizenship number

c. IflU.S, citizenship was derived by some other method. sttuch a statement of explunation.

d. If a Lawfrrl Permanent Resident of the United States, give A-Number

e. If a lawfully admitteel nonimmigranto give Fonrr I-94, Aruival-Deparftrre Recorcl, number

, I anr -3B" years of age and have resicle<i in the United Stares since
0B / 20 / rgBI
(D at e I n m / e{d/1'yy.y-J',1
3. l'his ailidavit is executed on behalf of the tbllowing person:
Narne (Fanrily Name) ( l irst
Age
Nguyen 8.1 a
55
Citizeu of (Country)
Relationship to Sponsor
Viet-nam
Aunt
Presently resides'at (Sheet Number and Narne)
(Country)
35th Street Vietnam
Name of spouse and
lne or cilloren accompanylng or tbllo.
ano children to lorn person:
)pouse Gender Age child Gender Age
Do, TLry Thi Ngoc F 2B
Ceuder Age child Gender Age

ld Gender Age child Gender' Age

4. 'l'his atldavit is rnade by nre for the purpose of assuring the U.S. Governnrent that the person(s) narne<J in
item (3) will not become a public
charge in the United States.
I aru willing and able [o receil'e, ntaintain, and support the person(s ) named in itern 3. I am
ready antl rvilling to dep.sir a bon4, if necessary, ro
guarantee that such person(s) will not becontc a public charge druing his
or her stay in the uniter] States, 1,1 to guamntee rhat the abovE narned
person(s)willrnai'rrtainlrisrrrherntrnimmigrantstatrrs,ifar1mittedtenlporrrril'y,anctwil'ldepartpricrrtoilreexpiratio
in the Unitetl States.
6. I understand that:
a' Forml-l34isan"undertaking"undersection2l3ofthelmnrigrationandNationalityAct,andImaybesuediftheperson(s)narnedinitem3
becomes a putrlic charge after admission to the United States;
b' Form l- I 3'1 may be rnade available to any Federal, state. or local agency that rnay
receive an applicatiorr fr.orn the person(s) narnecl in item 3
fol Food Stamps, Supplemental Security Incorne, or'femporary Asiistance to Needy Families;
and
c' lf the person(s) named in item 3 does apply fcrr Food starnps, supplernental Security lncorre,
or Temporary Assistance for Needy Families,
my own incotne and assets may be considered in deciding the person's application.
Ho* ton! roy iuci*e and assets rnay be attributed to the
person(s) tranred in item 3 is detennilled under the statutes an<l rules governing
each specific-progrun,.

FornrI-134 (l2lt9lt4 y pase I