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Department of Homeland Security
U.S. Citizenship and Immigration Services
I-914, Application for T Nonimmigrant Status
START HERE - Please type or print. Use black ink. See Instructions for
information about eligibility and how to complete and file this application.
For USCIS Use Only
Bar Code
PART A. Purpose for Filing the Application.
Check all that apply:
I am filing an application for T-1 nonimmigrant status, and have not previously filed for such
status.
I have a T-1 application pending. EAC #
Date Stamp
I have received T-1 status.
I am applying to bring family member(s) to the United States.
PART B. General Information About Applicant.
Family Name
Remarks
Given Name
Middle Name
Other Names Used (If any)? (Include maiden name and aliases)
Residence in the U.S. (Street Number and Name)
Apt. No.
City
State
Home Phone
Zip Code
Bona Fide Application
SAFE Mailing Address in the U.S., if other than above. Apt. No.
City
Daytime Phone
Zip Code
State
Initials
Stamp #
Date
Waiting List
Gender
Male
Female
Marital Status
Single
A# (If any)
Married
U.S Social Security # (If any)
Divorced
Widowed
Date of Birth (mm/dd/yyyy)
Initials
Stamp #
Date
Action Block
Country of Birth
Passport #
Country of Citizenship
Issue Date (mm/dd/yyyy)
Place of Issuance
I-94 #
Date of Last Entry into U.S.
Place of Last Entry into U.S.
Current Immigration Status
PART C. Details Related to T Nonimmigrant Status.
When answering the following questions about your claim you should explain relevant information. 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 only
applying for T derivative status subsequent to the Principal Applicant's initial filing, evidence supporting the original application is not required to be
resubmitted with the Form I-914. (Attach additional sheets of paper as needed, labeling them as Part C and the question number. Refer to Instructions
for further information.) Check either Yes or No, as appropriate.
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. (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
Form I-914 (07/30/07)Y
PART C. T Nonimmigrant Status. (Continued)
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,
please explain the circumstances.)
Yes
No
6. I am under the age of 18 years. (If Yes, proceed to Question 8.)
Yes
No
7. I have complied with requests from U.S. government authorities for assistance in the investigation or prosecution of acts
of trafficking. (If No, explain the circumstances. You may add additional pages if necessary, marking them Form I-914,
Part C.7.)
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
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
Law Enforcement Agency and
Office
Address
Phone No.
Case No.
Date of Entry
Place of Entry
Status
PART D. Processing Information.
Please answer the following questions. (If your answer is "Yes" to any one of these questions, explain on a separate piece of paper. Additionally, if
any of the acts or circumstances below are related to your having been a victim of a severe form of trafficking, please explain. Answering "Yes" does
not necessarily mean that you are not entitled to adjust your status or register for permanent residence.)
1.
Have you ever, in or outside the United States:
a. knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
b. been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance,
excluding traffic violations?
c. been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
d. exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States.?
2.
Have you ever received public assistance in the United States from any source, including the United States government or
any state, country, city or municipality (other than emergency medical treatment), or are you likely to receive public
assistance in the future?
3.
Have you ever:
a. within the past ten years been a prostitute or procured anyone for prostitution, or intend to engage in any such
activities in the future?
b. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
c. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the United States illegally?
d. illicitly trafficked in any controlled substance, firearms, or persons, or knowingly assisted, abetted or colluded in
illegal trafficking?
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Form I-914 (07/30/07)Y Page 2
PART D. Processing Information. (Continued)
4.
Have you ever engaged in, conspired to engage in, or do you intend to engage in, sabotage, kidnapping, political
assassination, hijacking or any other form of terrorist activity?
Yes
No
5.
Have you ever solicited membership or funds for, or have you through any means ever assisted or provided any
type of material support to, any person or organization that has engaged or conspired to engage in sabotage,
kidnapping, political assassination, hijacking or any other form of terrorist activity?
Yes
No
6.
Do you intend to engage in the United States in:
a. espionage?
b. any activity a purpose of which is opposition to, or the control or overthrow of, the government of the United
States, by force, violence or other unlawful means?
c. any activity to violate or evade any law prohibiting the export from the United States of goods, technology or
sensitive information?
Yes
Yes
No
No
Yes
No
7.
Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian
party?
Yes
No
8.
Did you, during the period from 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
order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national orgin
or political opinion?
Yes
No
9.
Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing
of any person because of race, religion, nationality, ethnic origin or political opinion?
Yes
No
10.
Have you ever been deported from the United States, or removed from the United States at government expense,
excluded within the past year, or are you now in exclusion or deportation proceedings?
Yes
No
11.
Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality Act for
use of fraudulent documents or have you, by fraud or willful misrepresentation of a material fact, ever sought to
procure, or procured, a visa, other documentation, entry into the United States or any immigration benefit?
Yes
No
12.
Have you ever left the United States to avoid being drafted into the U.S. Armed Forces?
Yes
No
13.
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?
Yes
No
14.
Are you now withholding custody of a U.S. citizen child outside the United States from a person granted custody of
the child?
Yes
No
15.
Do you plan to practice polygamy in the United States?
Yes
No
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, use a separate sheet of paper.
Full Name
Family
Relationship
Date of Birth
(mm/dd/yyyy)
"A"- Number
(if applicable)
Country
of Birth
Current Address
(Street, City, State and Country)
Complete Form I-914, Supplement A, Application for Immediate 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.
Form I-914 (07/30/07)Y Page 3
PART F. Attestation and Release.
After reading the information regarding penalties in the instructions, complete and sign below. If someone helped you prepare this application,
he or she must complete Part G.
I have read, or had read to me, this form, the information provided on it and the evidence provided with it, and I certify, under penalty of perjury
under the laws of the United States of America, that all of the information in this entire application package, including the documentary evidence
submitted with it, is true and correct.
I authorize the release of any information from my record that the U.S. Citizenship and Immigration Services needs to determine eligibility for the
benefit I am seeking, to investigate my claim and to investigate fraudulent claims. I further authorize the U.S. Citizenship and Immigration Services
to release information to law enforcement agencies and prosecutors investigating or prosecuting crimes of trafficking or related crimes.
Signature of Applicant (the Person in Part A.)
[
]
(Sign your name within the brackets)
Date ((mm/dd/yyyy)
PART G. Preparer and/or Translator Certification.
To be completed and signed if form is prepared by a person other than the applicant.
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and
correct.
(Preparer's/Translator's Signature)
(Preparer's/Translator's Printed Name)
Address
Phone Number
Date (mm/dd/yyyy)
Relationship to the Applicant
WARNING: Applicants who are in the United States illegally are subject to removal if their claims are not granted. Any
information provided in completing this application may be used as a basis for the institution of, or as evidence in, removal
proceedings even if the application is later withdrawn.
Form I-914 (07/30/07)Y Page 4
OMB No. 1615-0099; Expires 01/31/09
I-914, Supplement A-Application for
Immediate Family Member of T-1 Recipient
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Please type or print. Use black ink. See Instructions for information about eligibility and how to complete and file this
application. The recipient of the T nonimmigrant classification is referred to as the principal applicant. His or her family members are referred to as
derivative applicants. The Form I-914, Supplement A, is to be completed by the principal applicant.
For USCIS Use Only
PART A. Relationship.
The derivative applicant is my: (Check one)
Husband/Wife
Child
Bar Code
Parent
PART B. Information About Principal Applicant.
Family Name
Given Name
Date of Birth (mm/dd/yyyy)
Middle Name
Date Stamp
A# (If any)
Remarks
Principal applicant's application
has been previously: (Check One)
Submitted
Granted Conditional Approval
Found Bona Fide
Approved for T Nonimmigrant Status
PART C. Information About Derivative Applicant.
Family Name
Given Name
Middle Name
Action Block
A # (If any)
U. S. Social Security # (If any)
Other Names Used (If any)? (Include maiden name and aliases)
Intended Residence in U.S. (Street Number and Name)
State
ZIP Code
Apt. No.
Home Phone
Daytime Phone
SAFE Mailing Address in the U.S., if other than above. Apt. No.
Gender
Male
Female
Marital Status
Single
City
City
State
ZIP Code
Date of Birth (mm/dd/yyyy)
Married
Divorced
Widowed
Names of Prior Husband/Wives (if any), Dates Marriages Ended and Current Immigration Status (if any)
Country of Birth
Country of Citizenship
Passport #
Is the derivative applicant currently in the United States?
Yes (If Yes, complete the following.) He or she last arrived as a
(visitor, student, stowaway, without inspection, other, please
specify.) His or her status is
.
Has the derivative applicant previously entered the United States?
Date of Entry
Place of Entry
Issue Date (mm/dd/yyyy)
Place of Issuance
No (If No, please list the United States consulate by city and country,
where the derivative applicant will apply for a visa. (Designation
of a consulate outside of the country of your relative's last residence
does not guarantee acceptance for processing by that consulate.
Acceptance is at the discretion of the designated consulate.)
Yes
No (If Yes, list each previous entry during the past five years.
Attach additional sheets, if necessary.)
Status
Arrival/Departure Record (I-94) Number, date arrived, and date authorized stay expired, or will expire. (As shown on Form I-94 or I-95)
Form I-914, Supplement A (07/30/07)Y
PART C. Information About Derivative Applicant. (Continued)
Has family member for whom you are applying ever been under immigration proceedings?
Yes
No If Yes, answer the following:
Exclusion
Deportation
Where:
When (mm/dd/yyyy):
Recission
Judicial Proceeding
List your family member's spouse and children. (Attach additional sheets of paper, if necessary. If family member is your spouse, list only his or her
children.)
Name
Relationship
Date of Birth (mm/dd/yyyy)
Country of Birth
Are you applying for employment authorization for your family member?
Yes
No
(If Yes, submit a Form I-765, Application for
Employment Authorization, for the family member.)
PART D. Processing Information.
Please answer the following questions. (If your answer is "Yes" to any one of these questions, explain on a separate piece of paper. Answering "Yes"
does not necessarily mean that your family member will be denied T nonimmigrant status.)
1.
Has the family member for whom you are applying ever:
a. knowingly committed any crime of moral turpitude or a drug-related offense for which he or she have not been
arrested?
b. been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance,
excluding traffic violations?
c. been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
Yes
No
Yes
No
Yes
No
d. exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?
Yes
No
2.
Has the family member for whom you are applying ever received public assistance in the United States from any source,
including the U.S. government or any state, country, city or municipality (other than emergency medical treatment), or is
he or she likely to receive public assistance in the future?
Yes
No
3.
Has the family member for whom you are applying:
a. within the past ten years been a prostitute or procured anyone for prostitution, or does he or she intend to engage in
any such activities in the future?
b. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
c. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the United States illegally?
Yes
No
Yes
No
Yes
No
d. illicitly trafficked in any controlled substance, firearms, or persons, or knowingly assisted, abetted or colluded in
illegal trafficking?
Yes
No
4.
Has the family member for whom you are applying ever engaged in, conspired to engage in, or does he or she
intend to engage in, sabotage, kidnapping, political assassination, hijacking or any other form of terrorist activity?
Yes
No
5.
Has the family member for whom you are applying ever solicited membership or funds for, or through any means
ever assisted or provided any type of material support to, any person or organization that has engaged or conspired
to engage in sabotage, kidnapping, political assassination, hijacking or any other form of terrorist activity?
Yes
No
6.
Does the family member for whom you are applying intend to engage in the United States in:
a. espionage?
Yes
No
b. any activity a purpose of which is opposition to, or the control or overthrow of, the government of the United
States, by force, violence or other unlawful means?
c. any activity to violate or evade any law prohibiting the export from the United States of goods, technology or
sensitive information?
Yes
No
Yes
No
7.
Has the family member for whom you are applying ever been a member of, or in any way affiliated with, the
Communist Party or any other totalitarian party?
Yes
No
8.
Did the family member for whom you are applying, during the period from 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 order, incite, assist or otherwise participate in the persecution of any
person because of race, religion, national orgin or political opinion?
Yes
No
Form I-914, Supplement A (07/30/07)Y Page 2
PART D. Processing Information. (Continued)
9.
Has the family member for whom you are applying ever engaged in genocide, or otherwise ordered, incited,
assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin or
political opinion?
10. Has the family member for whom you are applying ever been deported from the United States, or removed from
the United States at government expense, excluded within the past year, or is he or she now in exclusion or
deportation proceedings?
11. Is the family member for whom you are applying under a final order of civil penalty for violating section 274C of
the Immigration and Nationality Act for use of fraudulent documents or has he or she, by fraud or willful
misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the
United States or any immigration benefit?
12. Has the family member for whom you are applying ever left the United States to avoid being drafted into the
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
United States Armed Forces?
13. Has the family member for whom you are applying 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?
14. Is the family member for whom you are applying now withholding custody of a U.S. citizen child outside the
United States. from a person granted custody of the child?
15. Does the family member for whom you are applying plan to practice polygamy in the United States?
PART E. Attestation and Release.
The Derivative Applicant, the family member for whom you are applying, must sign below if he or she is presently in the United States. If
someone helped you prepare this supplementary application, he or she must complete Part F.
I have read, or had read to me, this form, the information provided on it, and the evidence provided with it, and certify, under penalty of perjury
under the laws of the United States of America, that the information on this supplementary application and the evidence submitted with it are true
and correct.
I authorize the release of any information from the record that the U.S. Citizenship and Immigration Services needs to determine eligibility for the
benefit I am seeking for the family member for whom I am applying, to investigate my claim and to investigate fraudulent claims. I further authorize
the U.S.Citizenship and Immigration Services to release information to law enforcement agencies and prosecutors investigating or prosecuting
crimes of trafficking or related crimes.
[
]
Signature of Derivative Applicant (The family member for whom you
are applying.)
[
Date (mm/dd/yyyy)
]
Signature of Principal (Sign your name within the brackets)
Date (mm/dd/yyyy)
PART F. Preparer and/or Translator Certification.
To be completed and signed if this form is prepared by a person other than the applicant.
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and
correct.
(Preparer's/Translator's Printed Name)
(Preparer's/Translator's Signature)
Address
Phone Number
Date (mm/dd/yyyy)
Relationship to the Applicant
WARNING: Applicants who are in the United States illegally are subject to removal if their claims are not granted. Any information
provided in completing this application may be used as a basis for the institution of, or as evidence in, removal proceedings even if the
application is later withdrawn.
Form I-914, Supplement A (07/30/07)Y Page 3
PART G. Checklist.
I completely filled out and signed the form.
I have attached evidence that:
a.
b.
c.
d.
I am or have been a victim of a severe form of trafficking;
I am physically present in the United States on account of trafficking;
I am cooperating with the government in the investigation/prosecution of the traffickers (unless under age 18); and
I would suffer extreme hardship involving unusual and severe harm upon removal from the United States.
I have included three photographs of myself.
I have attached a check or money order for the required fees.
The required fees include:
a. The fee for filing this application;
b. The biometric services fee for fingerprinting the applicant, if the applicant is between the ages of 14 and 79 years, inclusive, and
c. If the applicant is also currently filing for family members, the appliant is responsible for additional charges, as detailed in the instructions to
Form I-914, Supplement A.
If I am applying for one or more family members:
I have completed a Form I-914, Supplement A for each member for whom I am now applying and, if he or she is in the United States, each
family member has signed that Form I-914, Supplement A.
I have submitted the required evidence, including evidence of:
a.
b.
c.
d.
My relationship to the family member for whom I am applying;
My age, if I am applying for my parent;
My child's age, if I am applying for my child; and
The extreme hardship that either I or my family member will suffer, if my family member is not permitted to join me in the United States.
I have included three photographs of each family member for whom I am now applying.
I have included a Form I-765 Application for Employment Authorization, if I am requesting employment authorization for my family member.
I have attached a check or money order for the required fees, or a request for a fee waiver.
The required fees include:
a. The fee for filing this supplementary application;
b. The biometric services fee for the applicant, if the applicant is between 14 and 79 years, inclusive, and must be fingerprinted,
or if the USCIS must also photograph the applicant or take his or her signature; and
c. The filing fee for Form I-765, Application for Employment Authorization, if the family member is requesting employment authorization.
Form I-914, Supplement A (07/30/07)Y Page 4
OMB No. 1615-0032; Expires 01/31/09
I-914, Supplement B-Declaration of Law Enforcement
Officer for Victim of Trafficking in Persons
Department of Homeland Security
U.S. Citizenship and Immigration Services
INSTRUCTIONS TO CERTIFYING OFFICER: This applicant is applying for immigration benefits based upon a claim of having been a victim
of a severe form of trafficking in persons. Please complete the form below based upon your knowledge of the case, including evidence developed by
other law enforcement officers investigating the case.
In order to be granted immigration benefits, the applicant must demonstrate that he or she is present in the United States as a result of being a victim
of a severe form of trafficking in persons. Unless the applicant is less than 18 years old, the applicant must also demonstrate that he or she is
cooperating with law enforcement in the investigation and prosecution of the trafficking crime of which he or she was a victim.
To be completed by Federal Law Enforcement Officers for victims under the Victims of Trafficking and Violence Protection Act, Public Law
106-386.
PART A. General Information.
Name of Government Agency:
U.S. Marshal's Service, DOJ
Federal Bureau of
Investigation, DOJ
Criminal Division, DOJ
U.S. Citizenship and
Immigration Services, DHS
Civil Rights Division, DOJ
Address of Agency/Official
City
U.S. Attorney's Office, DOJ
Date (mm/dd/yyyy)
Diplomatic Security, DOS
Other
Name and Title of Certifying Officer or Official
State
Victim's Name
ZIP Code
Phone No.
Gender
Other Names Used
Date of Crime(mm/dd/yyyy)
Charges
Date Initiated (mm/dd/yyyy)
Case Status
On-going
Fax No.
Date of Birth (mm/dd/yyyy)
Male
Female
Case No.
Date Completed (mm/dd/yyyy)
Completed
FBI Identification No., if any
N/A
PART B. Statement of Claim.
1.
The applicant is or has been a victim of a severe form of trafficking in persons. Specifically, he or she is a victim of: (Please check all that
apply. Base your analysis on the practices to which the victim was subjected rather than on the specific violations charged, the counts on which
convictions were obtained, or whether any prosecution resulted in convictions. Note that the definitions that control this analysis are not the
elements of criminal offenses, but are those set forth at 8 CFR 214.11(a).)
Sex trafficking in which a commercial sex act was induced by force, fraud or coercion. Sex trafficking means the recruitment, harboring,
transportation, provision, or obtaining of a person for the purpose of a commercial sex act.
Sex trafficking and the victim is under the age of 18.
The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud or
coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.
Not applicable.
Other, please specify on attached additional sheets.
2.
Please describe the victimization upon which the applicant's claim is based and identify the relationship between that victimization and the
crime under investigation/prosecution. Attach the results of any name or database inquiry performed in the investigation of the case. Please
include relevant dates, etc. Attach additional sheets, if necessary.
3.
Has the applicant expressed any fear of retaliation or revenge if removed from the United States? If yes, please explain. Attach additional
sheets, if necessary.
Form I-914, Supplement B (07/30/07)Y
PART C. Cooperation of Victim. (Attach additional sheets, if necessary.)
The applicant:
Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has not been requested to assist in the investigation/prosecution of any crime of trafficking.
Has not yet attained the age of 18.
Other, please specify on attached additional sheets.
PART D. Family Members.
Yes
No Are any of the applicant's relatives believed to have been involved in his or her trafficking to the United States? If Yes, list
the relatives and describe that relative's involvement in the applicant's trafficking.
PART E. Attestation.
Based upon investigation of the facts, I certify, under penalty of perjury, that the above noted individual is or has been a victim of a severe form of
trafficking in persons as defined by the VTVPA. I certify that the above information is true and correct to the best of my knowledge, and that I have
made, and will make, no promises regarding the above victim's ability to obtain a visa from the U.S. Citizenship and Immigration Services, based
upon this certification.
[
]
(Signature of Law Enforcement Officer
identified in Box A above)
[
Date (mm/dd/yyyy)
]
(Signature of Supervisor of Certifying Officer)
(Printed Name of Supervisor)
Date (mm/dd/yyyy)
Form I-914, Supplement B (07/30/07)Y Page 2
| File Type | application/pdf |
| File Modified | 2007-06-27 |
| File Created | 2007-06-27 |