I-914 Frm Toc

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TABLE OF CHANGES – FORM

Form I-914, Application for T Nonimmigrant Status

OMB Number: 1615-0099

02/17/2021

Reason for Revision: Revision

Project Phase: 30 Day

Legend for Proposed Text:

• Black font = Current text

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Expires 04/30/2021

Edition Date 10/02/2020

Current Page Number and Section	Current Text	Proposed Text
Page 1, To Be Completed by Attorney or Representative, if any	[Page 1] To Be Completed by Attorney or Representative, if any Fill in box if G-28 is attached to represent the applicant. ATTY State License #	[Page 1] To be fully completed by an attorney or accredited representative, if any. Select this box if Form G-28 is attached. Attorney State Bar Number Attorney or Accredited Representative USCIS Online Account Number
Page 1, PART A. Purpose for Filing the Application	[Page 1] START HERE - Type or print. Use black ink. See Instructions for information about eligibility and how to complete and file this application. PART A. Purpose for Filing the Application Check all that apply: I am filing for T-1 nonimmigrant status and have not previously filed for such status. I am filing for T-1 nonimmigrant status and have previously filed for such status. Receipt Number (begins with EAC) I have received T-1 status and am applying to bring family members to the United States.	[Page 1] START HERE - Type or print in ink. Part 1. Purpose for Filing This Application Select all applicable boxes. 1.A. I am filing for T-1 nonimmigrant status and have not previously filed for such status. B. I am filing for T-1 nonimmigrant status and have previously filed for such status. (Provide receipt number below.) (1) Receipt Number EAC [Fillable Field] [deleted]
Page 1, PART B. General Information About You (Person filing this form as a victim)	[Page 1] PART B. General Information About You (Person filing this form as a victim) Family Name (Last Name) Given Name (First Name) Middle Name (if any) Other Names Used (Include maiden name/nickname) Home Address - Street Number and Name Apt. Number City State/Province Zip/Postal Code Safe Mailing Address (if other than above) – C/O (in care of): Street Number and Name Apt. Number City State/Province Zip/Postal Code Home Telephone Number (with area code) Safe Daytime Phone Number (with area code) E-Mail Address (optional) A-Number (if any) U.S. Social Security Number (if any) Gender Male Female Marital Status: Single/Never Married Married Divorced Widowed Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship Passport Number Place of Issuance Date of Issue (mm/dd/yyyy) Place of Last Entry Date of Last Entry (mm/dd/yyyy) Form I-94 Number (Arrival-Departure Record) Current Immigration Status	[Page 1] Part 2. General Information About You (Person filing this application as a victim) 1. Your Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Other Names Used Provide any other names you have used since birth, including aliases, maiden names, and nicknames. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Family Name (Last Name) [x2] Given Name (First Name) Middle Name (if any) 3. Physical Address Street Number and Name Apt. Ste. Flr. [Number] City or Town State ZIP Code [Page 2] 4. Safe Mailing Address If you do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home address, you may provide an alternate safe mailing address. In Care Of Name Street Number and Name Apt./Ste./Flr. [Number] City or Town State ZIP Code [delete] 5. Alien Registration Number (A-Number) (if any) 6. USCIS Online Account Number (if any) 7. U.S. Social Security Number (SSN) (if any) 8. Gender Male Female 9. Marital Status Single/Never Married Married Divorced Widowed 10. Date of Birth (mm/dd/yyyy) 11. Place of Birth City or Town State or Province Country 12. Country of Citizenship or Nationality 13. Passport or ­Travel Document Number (if any) 14. Country That Issued Your Passport or Travel Document (if any) 15. Issue Date for Passport or Travel Document (mm/dd/yyyy) (if any) 16. Expiration Date for Passport or Travel Document (mm/dd/yyyy) (if any) 17. Place of Your Last Entry Into the United States City or Town State 18. Date of Your Last Entry Into the United States, On or About (mm/dd/yyyy) 19. Form I-94 Arrival-Departure Record Number (if any) 20. Your Current Immigration Status
Pages 2-3, PART C. Additional Information	[Page 2] PART C. Additional Information Answers to the following questions about your claim require explanation and supporting documentation. You should attach documents in support of your claim that you are a victim of a severe form of trafficking in persons and the specific facts on which you are relying to support your claim. You must attach a personal narrative statement describing the trafficking. If you are only applying for T derivative status for a family member subsequent to your (the principal applicant) initial filing, evidence supporting the original application is not require to be resubmitted with the new Form I-914. Attach additional sheets of paper as needed. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet and indicate the number of the item that you are answering. Include the Part and letter or number relating to the additional information you provided (example: Part C, 3). 1. I am or have been a victim of a severe form of trafficking in persons. (Attach evidence to support your claim.) Yes No 2. I am submitting a law enforcement agency (LEA) declaration on Form I-914, Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons. (If "No," explain why you are not submitting the LEA Certification.) Yes No 3. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana Islands, or at a port of entry, on account of trafficking, or have been allowed entry into the United States to participate in investigative or judicial processes associated with an act or perpetrator of trafficking. (If "Yes," explain in detail and attach evidence and documents supporting this claim.) Yes No 4. I fear that I will suffer extreme hardship involving unusual and severe harm upon removal. (If "Yes," explain in detail and attach evidence and documents supporting this claim.) Yes No 5. I have reported the crime of which I am claiming to be a victim. (If "Yes," indicate to which law enforcement agency and office you have made the report, the address and phone number of that office, and the case number assigned, if any. If "No," explain the circumstances.) Yes No Law Enforcement Agency and Office Address Phone Number Case Number Circumstances: 6. I am under the age of 18 years. (If "Yes," proceed to Question 8.) Yes No 7. I have complied with requests from Federal, State, or local law enforcement authorities for assistance in the investigation or prosecution of acts of trafficking, or am unable to cooperate with such requests due to physical or psychological trauma. (If "No," explain the circumstances.) Yes No 8. This is the first time I have entered the United States. (If "No," list each date, place of entry, and under which status you entered the United States for the past five years, and explain the circumstances of your most recent arrival.) Yes No Date of Entry Place of Entry Status [Page 3] 9. My most recent entry was on account of the trafficking that forms the basis for my claim. (Explain the circumstances of your most recent arrival.) Yes No 10. I want an Employment Authorization Document. Yes No 11. I am now applying for one or more eligible family members. (If "Yes," complete and include a Form I-914, Supplement A, Application for Immediate Family Member of T-1 Recipient, for each family member for whom you are now applying. You may also apply to bring eligible family members to the United States at a later date.) Yes No	[Page 3] Part 3. Additional Information About Your Application Answers to the following questions about your claim require explanation and supporting documentation. You should attach documents in support of your claim that you are a victim of a severe form of trafficking in persons and the specific facts on which you are relying to support your claim. You must attach a personal narrative statement addressing the eligibility requirements for T nonimmigrant status as listed in the regulations, including a description of the trafficking you experienced. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. [deleted] 1. I am or have been a victim of a severe form of trafficking in persons. (Attach evidence to support your claim.) Yes No 2.A. I have cooperated with reasonable requests for assistance from law enforcement. Yes No 2.B. Due to my age or the trauma I have suffered, I am exempt from the requirement to cooperate with reasonable requests for assistance from law enforcement. Yes No 3. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana Islands, or at a port of entry, on account of trafficking, or have been allowed entry into the United States to participate in investigative or judicial processes associated with an act or perpetrator of trafficking. (If you selected “Yes,” explain in detail and attach evidence and documents supporting this claim.) Yes No 4. I fear that I will suffer extreme hardship involving unusual and severe harm upon removal. (If you selected “Yes,” explain in detail and attach evidence and documents supporting this claim.) Yes No 5. I have reported the trafficking crime of which I am claiming to be a victim. (If you selected “Yes,” indicate to which law enforcement agency and office you have made the report, the address and phone number of that office, and the case number assigned, if any. If you selected “No,” explain the circumstances.) Yes No Law Enforcement Agency and Office Street Number and Name Apt./Ste./Flr. [Number] City or Town State ZIP Code Daytime Telephone Number Case Number Circumstances 6. I am under 18 years of age. (If you selected "Yes," skip to Item Number 8.) Yes No 7. I have complied with reasonable requests from Federal, state, local, or tribal law enforcement authorities for assistance in the investigation or prosecution of acts of trafficking, or am unable to cooperate with such requests due to physical or psychological trauma. (If you selected “No,” explain the circumstances.) Yes No 8. This is the first time I have entered the United States. (If you selected “No,” list each date, place of entry, and under which status you entered the United States for the past five years, and explain the circumstances of your most recent arrival.) If you need extra space, use the space provided in Part 9. Additional Information. Yes No (1) Date of Entry (mm/dd/yyyy) (2) Place of Entry City or Town State (3) Status [Page 4] 9. My most recent entry was on account of the trafficking that forms the basis for my claim. (Explain the circumstances of your most recent arrival.) Yes No 10. I am requesting an Employment Authorization Document (EAD). Yes No 11. I am now applying for one or more eligible family members. (If you selected “Yes,” complete and include a Form I-914, Supplement A, Application for Immediate Family Member of T-1 Recipient, for each family member for whom you are now applying. You may also apply to bring eligible family members to the United States at a later date.) Yes No
Pages 3-6, Part D. Processing Information	[Page 3] PART D. Processing Information Answer the following questions about yourself. For purposes of this application, if applicable, you must answer “Yes” to the following questions, even if your records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. (If your answer is "Yes" to any one of these questions, explain on a separate sheet of paper. Additionally, explain if any of the acts or circumstances below are related to you having been a victim of a severe form of trafficking. Answering "Yes" does not necessarily mean that you will be denied T nonimmigrant status or are not entitled to adjust your status or register for permanent residence.) 1. Have you EVER: a. Committed a crime or offense for which you have not been arrested? Yes No b. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military officers) for any reason? Yes No c. Been charged with committing any crime or offense? Yes No d. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)? Yes No e. Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes No f. Received a suspended sentence, been placed on probation, or been paroled? Yes No g. Been in jail or prison? Yes No h. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action? Yes No i. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States? Yes No If you answered “Yes” to any of the above questions, complete the following table. If you need more space, use a separate sheet of paper to give the same information. [Table with 4 columns, 2 rows] Why were you arrested, cited, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where were you arrested, cited, detained, or charged? (City, State, Country) Outcome or disposition (e.g., no charges filed, charges dismissed, jail, probation, etc.) [Page 4] 2. Have you: a. Engaged in prostitution or procurement of prostitution or do you intend to engage in prostitution or procurement of prostitution? Yes No b. EVER engaged in any unlawful commercialized vice, including, but not limited to illegal gambling? Yes No c. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? Yes No d. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? Yes No 3. Have you EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered information for, or solicited funds for any of the following: a. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No b. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No c. Assassination? Yes No d. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No e. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No 4. Have you EVER been a member of, solicited money or members for, provided support for, attended military training (as defined in section 2339D(c)(1) of title 18, United States Code) by or on behalf of, or been associated with an organization that is: a. Designated as a terrorist organization under section 219 of the Immigration and Nationality Act? Yes No b. Any other group of two or more individuals, whether organized or not, which has engaged in or has a subgroup which has engaged in: 1. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No 2. Seizing or detaining, and threatening to kill, injure, or continue to detain another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No 3. Assassination? Yes No 4. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No 5. Soliciting money or members or otherwise providing material support to a terrorist organization? Yes No 6. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive, or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No [Page 5] 5. Do you intend to engage in the United States in: a. Espionage? Yes No b. Any unlawful activity, or any activity the purpose of which is in opposition, to control, or overthrow of the government of the United States? Yes No c. Solely, principally, or incidentally in any activity related to espionage or sabotage or to violate any law involving the export of goods, technology, or sensitive information? Yes No 6. Have you ever been or do you continue to be a member of the Communist or other totalitarian party, except when membership was involuntary? Yes No 7. Have you, during the period of March 23, 1933, to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, nationality, membership in a particular social group, or political opinion? Yes No 8. Have you EVER been present or nearby when any person was: a. Intentionally killed, tortured, beaten, or injured? Yes No b. Displaced or moved from his or her residence by force, compulsion, or duress? Yes No c. In any way compelled or forced to engage in any kind of sexual contact or relations? Yes No 9. a. Are removal, exclusion, rescission, or deportation proceedings pending against you? Yes No b. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against you? Yes No c. Have you EVER been removed, excluded, or deported from the United States? Yes No d. Have you EVER been ordered to be removed, excluded, or deported from the United States? Yes No e. Have you EVER been denied a visa or denied admission to the United States? (If a visa was denied, explain why on a separate sheet of paper.) Yes No f. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge and failed to depart within the allotted time? Yes No 10. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: a. Acts involving torture or genocide? Yes No b. Killing any person? Yes No c. Intentionally and severely injuring any person? Yes No d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Yes No e. Limiting or denying any person's ability to exercise religious beliefs? Yes No 11. Have you EVER: a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Yes No b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Yes No [Page 6] 12. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so? Yes No 13. Have you EVER assisted or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person? Yes No 14. Have you EVER received any type of military, paramilitary, or weapons training? Yes No 15. Are you under a final order or civil penalty for violating section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)? Yes No 16. Have you EVER, by fraud or willful misrepresentation of a material fact, sought to procure, or procured, a visa or other documentation, for entry into the United States or any immigration benefit? Yes No 17. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces? Yes No 18. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement and not yet complied with that requirement or obtained a waiver of such? Yes No 19. Have you EVER detained, retained, or withheld the custody of a child, having a lawful claim to U.S. citizenship, outside the United States from a U.S. citizen granted custody? Yes No 20. Do you plan to practice polygamy in the United States? Yes No 21. Have you entered the United States as a stowaway? Yes No 22. a. Do you have a communicable disease of public health significance? Yes No b. Do you have or have you had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others? Yes No c. Are you now or have you been a drug abuser or drug addict? Yes No	[Page 3] Part 4. Processing Information Answer the following questions about yourself. Responses are intended to cover any activity you have committed under your legal name or any aliases. For purposes of this application, you must answer “Yes” to the following questions, even if your records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. (If your answer is "Yes" to any one of these questions, explain in the space provided in Part 9. Additional Information. Additionally, explain if any of the acts or circumstances below are related to you having been a victim of a severe form of trafficking. Answering "Yes" does not necessarily mean that you will be denied T nonimmigrant status or are not entitled to adjust your status or register for permanent residence.) 1. Have you EVER: A. Committed a crime or offense for which you have not been arrested? Yes No B. Been arrested, cited, or detained by any law enforcement officer (including Department of Homeland Security (DHS), former Immigration and Naturalization Service (INS), and military officers) for any reason? Yes No C. Been charged with committing any crime or offense? Yes No D. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)? Yes No E. Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes No F. Received a suspended sentence, been placed on probation, or been paroled? Yes No G. Been in jail or prison? Yes No H. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action? Yes No I. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States? Yes No If you answered “Yes” to any of the above questions, complete the following table. If you need extra space, use the space provided in Part 9. Additional Information. [Table with 4 columns, 2 rows] Why were you arrested, cited, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where were you arrested, cited, detained, or charged? (City or Town, State, Country) Outcome or disposition (for example, no charges filed, charges dismissed, jail, probation, etc.) [Page 5] 2. Have you: A. Engaged in prostitution or procurement of prostitution or do you intend to engage in prostitution or procurement of prostitution? Yes No B. EVER engaged in any unlawful commercialized vice, including, but not limited to illegal gambling? Yes No C. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? Yes No D. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? Yes No 3. Have you EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered information for, or solicited funds for any of the following: A. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No B. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No C. Assassination? Yes No D. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No E. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No 4. Have you EVER been a member of, solicited money or members for, provided support for, attended military training (as defined in section 2339D(c)(1) of title 18, United States Code) by or on behalf of, or been associated with an organization that is: A. Designated as a terrorist organization under the Immigration and Nationality Act section 219? Yes No B. Any other group of two or more individuals, whether organized or not, which has engaged in or has a subgroup which has engaged in: (1) Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes No (2) Seizing or detaining, and threatening to kill, injure, or continue to detain another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes No (3) Assassination? Yes No (4) The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property? Yes No (5) Soliciting money or members or otherwise providing material support to a terrorist organization? Yes No (6) The use of any biological agent; chemical agent; or nuclear weapon or device; explosive, or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property? Yes No 5. Do you intend to engage in the United States in: A. Espionage? Yes No B. Any unlawful activity, or any activity the purpose of which is in opposition, to control, or overthrow of the government of the United States? Yes No C. Solely, principally, or incidentally in any activity related to espionage or sabotage or to violate any law involving the export of goods, technology, or sensitive information? Yes No [Page 6] 6. Have you ever been or do you continue to be a member of the Communist or other totalitarian party, except when membership was involuntary? Yes No 7. Have you, during the period of March 23, 1933, to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, nationality, membership in a particular social group, or political opinion? Yes No 8. Have you EVER been present or nearby when any person was: A. Intentionally killed, tortured, beaten, or injured? Yes No B. Displaced or moved from his or her residence by force, compulsion, or duress? Yes No C. In any way compelled or forced to engage in any kind of sexual contact or relations? Yes No 9. A. Are removal, exclusion, rescission, or deportation proceedings pending against you? Yes No B. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against you? Yes No C. Have you EVER been removed, excluded, or deported from the United States? Yes No D. Have you EVER been ordered to be removed, excluded, or deported from the United States? Yes No E. Have you EVER been denied a visa or denied admission to the United States? (If a visa was denied, use the space provided in Part 9. Additional Information.) Yes No F. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge and failed to depart within the allotted time? Yes No 10. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: A. Acts involving torture or genocide? Yes No B. Killing any person? Yes No C. Intentionally and severely injuring any person? Yes No D. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Yes No E. Limiting or denying any person's ability to exercise religious beliefs? Yes No 11. Have you EVER: A. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Yes No B. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Yes No 12. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so? Yes No 13. Have you EVER assisted or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person? Yes No 14. Have you EVER received any type of military, paramilitary, or weapons training? Yes No 15. Are you under a final order or civil penalty for violating section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)? Yes No 16. Have you EVER, by fraud or willful misrepresentation of a material fact, sought to procure, or procured, a visa or other documentation, for entry into the United States or any immigration benefit? Yes No 17. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces? Yes No [Page 7] [deleted] 18. Have you EVER detained, retained, or withheld the custody of a child, having a lawful claim to U.S. citizenship, outside the United States from a U.S. citizen granted custody? Yes No 19. Do you plan to practice polygamy in the United States? Yes No 20. Have you entered the United States as a stowaway? Yes No 21. A. Do you have a communicable disease of public health significance? Yes No B. Do you have or have you had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others? Yes No C. Are you now or have you been a drug abuser or drug addict? Yes No
Pages 6-7, PART E. Information About Your Family Members	[Page 6] PART E. Information About Your Family Members Provide the following information about your spouse and all of your sons and daughters. If you need more space, attach an additional sheet of paper. 1. Spouse Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Current Location [Page 7] 2. Children a. Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location b. Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location c. Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location Complete Form I-914, Supplement A, Application for Family Member of T-1 Recipient, for each family member listed above for whom you are now applying to have join you in the United States, and attach it to this application.	[Page 7] Part 5. Information About Your Family Members Provide the following information about your spouse and all of your children, if applicable. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. 1. Your Spouse’s Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Current Location City or Town of Residence Country of Residence [Page 7] 5. Information About Your Children A. Child 1 Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location City or Town State Country [Page 8] B. Child 2 Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location City or Town State Country C. Child 3 Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Current Location City or Town State Country Complete Form I-914, Supplement A, Application for Family Member of T-1 Recipient, for each family member listed above for whom you are now applying for derivative T nonimmigrant status, and attach it to this application.
Pages 7-8, PART F. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature	[Page 7] PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. B. The interpreter named in Part G. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part H., [Fillable Field], prepared this application for me based only upon information I provided or authorized. [Page 8] Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I authorize the release of any information from my record that USCIS needs to determine eligibility for the benefit I am seeking to investigate my claim, and to investigate fraudulent claims. I further authorize USCIS to release information to law enforcement agencies and prosecutors investigating crimes of trafficking or related crimes. I further authorize USCIS to release information to Federal, State, and local public and private agencies providing benefits, to be used solely in making determinations of eligibility for benefits pursuant to 8 USC 1641(c). I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Signature 6. Applicant's Signature (sign in ink) Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.	[Page 8] Part 6. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-914 Instructions before completing this section. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. B. The interpreter named in Part 7. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 8., [Fillable Field], prepared this application for me based only upon information I provided or authorized. [Page 9] Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Safe Daytime Telephone Number 5. Applicant's Email Address (if any) Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I authorize the release of any information from my record that USCIS needs to determine eligibility for the benefit I am seeking to investigate my claim, and to investigate fraudulent claims. I further authorize USCIS to release information to law enforcement agencies and prosecutors investigating crimes of trafficking or related crimes. I further authorize USCIS to release information to Federal, State, and local public and private agencies providing benefits, to be used solely in making determinations of eligibility for benefits pursuant to 8 USC 1641(c). I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Signature 6. Applicant's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.
Page 9, PART G. Interpreter’s Contact Information, Certification, and Signature	[Page 9] PART G. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part F., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature (sign in ink) Date of Signature (mm/dd/yyyy)	[Page 9] Part 7. Interpreter's Contact Information, Certification, and Signature (if any) Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) [Page 10] Interpreter's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 6., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)
Page 10, PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 10] PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer's Statement 7. A. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. B. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature (sign in ink) Date of Signature (mm/dd/yyyy)	[Page 10] Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) [Page 11] Preparer's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer's Statement 7. A. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. B. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature Date of Signature (mm/dd/yyyy)
		[Page 11] Part 9. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers. 1. Family Name (Last Name) [Auto-populated field] Given Name (First Name) [Auto-populated field] Middle Name [Auto-populated field] 2. A-Number [Auto-populated field] 3. A. Page Number B. Part Number C. Item Number D. [Fillable field] 4. A. Page Number B. Part Number C. Item Number D. [Fillable field] 5. A. Page Number B. Part Number C. Item Number D. [Fillable field] 6. A. Page Number B. Part Number C. Item Number D. [Fillable field]

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