'. 1 11 11pl1y1d 1s 11 1n1111d in th2 busin1ss 1f with
(%yp1 1f Busin1ss) (N111 1f C1nc11n)
(St111t Nu1b11 1nd N111
1 d11iv1 1n 1nnu1l inc111 1f: (If self-e]plo]e], I have attache] a cop] of ]] last inco]e tax return or report of co]]ercial rating concern which I certif] to be true an] correct to the best of ]] knowle]ge
an] belief. See instructions for nature of evi]ence of net worth to be sub]itte].) 7
1 h2v1 1n d1p1sit in s1vin1s b1nks in th2 Unit1d St1t1s: 7
1 h2v1 1th21 p11s1n1l p11p11ty, th2 111s1n1bl1 v1lu1 1f which is: 7
1 h2v1 st1cks 1nd b1nds with th2 f1ll1win1 111k1t v1lu1, 1s indic1t1d 1n th2 1tt1ch2d list, which 1 c11tify
(If ]ou check "inten]," in]icate the exact nature an] ]uration of the contributions. For exa]ple, if ]ou inten] to furnish roo] an] boar], state for how long an], if ]one], state the a]ount in U..S. ]ollars an] whether it is to be given in a lu]p su], weekl] or ]onthl], an] for how long.
+ath or Affirmation of Spon+or
1 acknowledge that 1 have read "Spon+or and Alien Liability" on Page 2 of the in+truction+ for thi+ form, and am aware of my re+pon+ibilitie+ a+ a +pon+or under the Social Security Act, a+ amended, and the Food Stamp Act, a+ amended.
1 certify under penalty of perjury under United State+ law that 1 know the content+ of thi+ affidavit +igned by me and that the +tatement+ are true and correct.