8.a.

StreetNumber 1133 Hampton Dupree Rd

ll.c. I I derived my U.S. citizenship by another method. and Name
(Provide an explain in Part 7. Additional 8.b. EApt. Hste. HFlr.
Information.)

11.d. E I am a lawful permanent resident of the 8.c. CityorTown Pine Prarie

United States. My A-Number is
8.d. State 8.e. ZIPcode 70576

11.e. I I am a lawfully admitted nonimmigrant. My 8.f. Province

Form I-94, Arrival-Departure Record Number is
8.g. Postal code

8.h. Country
12. lam Eyearsofageandhave resided in the United
States since (Date) (mm/dd/yyyy) 07 / OJ I 1986

9.a. Family Name

This affidavit is executed on behalf of the following person: (Last Name)
1.a. Family Name 9.b. GivenName
Bohorquez
(Last Name) (First Name)
I.b. GivenName 9.c. MiddleName
(First Name)
I.c. MiddleName 10. Date of Birth (mm/dd/yyyy) I I

2. Date of Birth (mm/dd/yyyy) I I 11. Gender EMale EFemale

3. Gender EEMale HFemale

4. A-Number(if any)
Child 1
+A-
12.a. Family Name
5. Country of citizenship or Nationality (Last Name)
12.b. Given Name
Venezuela
(First Name)
6. Marital status 12.c. Middle Name
E Single or Single, Never Married
13. Date of Birth (mm/dd/yyyy) I I
E Married
I Divorced 14. Gender EMale EFemale

I Widowed
Child 2
I Legally Separated 15.a. Family Name
I Marriage Amulled (Last Name)
15.b. Given Name
I Other (First Name)
7. Relationship to sponsor 15.c. Middle Name
Nephew
16. Date of Birth (mm/dd/yyyy) I I

17. Gender EMale EFemale

If you need additional space to complete this section, use the
space provided in Part 7. Additional Information.

Form I-134 02/13/19 Page 2 of 8