Pages
2-3,
Part
3. Additional Information About
Your Application
|
[Page
2]
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.
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
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
[Page
3]
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
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
|
[Page 2]
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. If
you answer “Yes” to Item
Numbers
1.
- 4.,
attach evidence and documents to support your claim. You
must attach
a
signed 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.
1.
I
am
or
have
been
a
victim
of
a
severe
form
of
trafficking
in
persons.
Yes
No
2.A.
I have cooperated with reasonable requests for assistance from
law enforcement.
Yes
No
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
[Page
3]
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.
Yes
No
4.
I
fear that I will suffer extreme hardship involving unusual and
severe harm upon removal.
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
below.)
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
was
under
18 years of age
at the time at least one of the acts of trafficking occurred.
Yes
No
7.
I
have complied with reasonable requests from Federal, State,
Tribal, 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 you
selected
“No,”
and were over 18 years of age at the time one of the acts of
trafficking occurred, 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
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)
when I am granted T nonimmigrant status.
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
Derivative T Nonimmigrant Status, 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
4-7
Part
4. Processing
Information
|
[Page
4]
Part
4. Processing
Information
…
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
…
(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
…
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
…
|
[Page 4]
Part
4. Processing
Information
…
D.
The
use
of any
firearm
with
intent
to
endanger,
directly
or
indirectly,
the
safety
of
one
or
more
individuals
or
to
cause
substantial
damage
to
property?
Yes
No
…
(4)
The
use
of any
firearm
with
intent
to
endanger,
directly
or
indirectly,
the
safety
of
one
or
more individuals
or
to
cause
substantial
damage
to
property?
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
their
residence
by
force,
compulsion,
or
duress?
Yes
No
…
|
Pages
7-8
Part
5.
Information
About Your Family
Members
|
[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
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
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
[Page
8]
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.
|
[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.
Information
About your Spouse
A.
Your
Spouse’s Legal Name
Family
Name
(Last Name)
Given
Name
(First
Name)
Middle
Name
(if any)
B.
Date
of Birth
(mm/dd/yyyy)
C.
Country
of Birth
D.
Current Location
City or
Town of Residence
Country of
Residence
2.
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
[deleted]
Current
Location
City
or Town
State
Country
B.
Child
2
Family
Name
(Last Name)
Given
Name
(First
Name)
Middle
Name
(if any)
Date
of Birth
(mm/dd/yyyy)
Country
of Birth
[deleted]
Current
Location
City
or Town
State
Country
[Page
8]
C.
Child
3
Family
Name
(Last Name)
Given
Name
(First
Name)
Middle
Name
(if any)
Date
of Birth
(mm/dd/yyyy)
Country
of Birth
[deleted]
Current
Location
City
or Town
State
Country
[deleted]
|
Pages
8-9
Part
6.
Applicant's
Statement, Contact Information, Declaration,
Certification,
and
Signature
|
[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.
Applicant's
Contact
Information
3.
Applicant's
Daytime
Telephone
Number
4.
Applicant's
Safe
Daytime Telephone Number
5.
Applicant's
Email
Address
(if
any)
[Page
9]
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 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.
Applicant's
Contact
Information
3.
Applicant's
Daytime
Telephone
Number
4.
Applicant's
Safe
Daytime Telephone Number
5.
Applicant's
Email
Address
(if
any)
[Page
9]
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
U.S.C.
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.
Any
disclosure will be in accordance with the confidentiality
provisions at 8 U.S.C. section 1367 and 8 CFR 214.216.
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
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
the
information
in
my
application
and
any
document
submitted
with
it
were
provided
or
authorized
by
me,
that
I
reviewed
and
understand
all
the
information
contained
in,
and
submitted
with,
my
application
and
that
all
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.
|
Pages
9-10
Part
7.
Interpreter's
Contact
Information, Certification,
and
Signature (if any)
|
[Page
9]
Part
7.
Interpreter's
Contact
Information, Certification,
and
Signature (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 9]
Part
7.
Interpreter's
Contact
Information, Certification,
and
Signature (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
their
answer
to
every
question.
The
applicant
informed
me
that
they
understand
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)
|
Pages
10-11
Part
8.
Contact
Information, Declaration,
and
Signature
of
the Person
Preparing
this
Application,
if
Other
Than
the Applicant
|
[Page
10]
Part
8.
Contact
Information, Declaration,
and
Signature
of
the Person
Preparing
this
Application,
if
Other
Than
the Applicant
…
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 10]
Part
8.
Contact
Information, Declaration,
and
Signature
of
the Person
Preparing
this
Application,
if
Other
Than
the Applicant
…
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
they
understand
all
the
information
contained
in,
and
submitted
with,
their
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)
|