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Sponsor, please complete this form or the I-134 Affidavit of
Please note you must sign this document with a blue or black pen. Electronic signatures will not be accepted. Page 2. IMPORTANT, PLEASE READ: Bank Statement
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billing Guidelines
Jan 29, 2009 The person who obtained consent from the patient must sign and date the form. If the sterilization is to be performed in New York City, this
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*Please note that only ONE section/side of the form should
Providers should maintain the form in the childs file. Please use a blue or black pen, press firmly, and PRINT legibly. Parents or Guardians will
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