Form I-914 Application for T Nonimmigrant Status

OMB No. 1615-0099; Expires 05/31/2014

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-914, Application for T Nonimmigrant Status

START HERE - Type or print. Use black ink. See Instructions for information

For USCIS Use Only

about eligibility and how to complete and file this application.

Returned

PART A. Purpose for Filing the Application

Date

Receipt

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
Resubmitted
Date

I have received T-1 status.
Date
Reloc Sent

I am applying to bring family member(s) to the United States.

PART B. General Information About You (Person filing this form as a victim)
Family Name (Last Name)

Given Name (First Name)

Date

Middle Name (if any)
Date
Reloc Rec'd

Other Names Used (Include maiden name/nickname)

Date
Home Address - Street Number and Name
City

Apt. #

State/Province

Zip/Postal Code

Date
Validity Dates
From:
To:

Safe Mailing Address (if other than above) - Street Number and Name

Apt. #

Remarks

C/O (in care of):
City
Home Telephone #
(with area code)

State/Province
Safe Daytime Phone #
(with area code)

Zip/Postal Code
E-Mail Address
(optional)

Conditional Approval
Stamp #

A # (if any)

Marital Status:
Married

U.S. Social Security # (if any)

Single/Never Married

Date of Birth (mm/dd/yyyy) Country of Birth

Passport #

Place of Issuance

Gender
Male

Divorced

Date

Action Block
Female
Widowed

Country of Citizenship

Date of Issue (mm/dd/yyyy)
To Be Completed by
Attorney or Representative, if any

Place of Last Entry
I-94 # (Arrival/Departure Document)

Date of Last Entry (mm/dd/yyyy)
Current Immigration Status

Fill in box if G-28 is attached to
represent the applicant.
ATTY State License #
Form I-914 (05/04/12) Y

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. It is strongly encouraged that you 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 required 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. (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. (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

Form I-914 (05/04/12) Y Page 2

PART C. Additional Information

(Continued)
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

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.)

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.
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.)

Form I-914 (05/04/12) Y Page 3

PART D. Processing Information

(Continued)
Yes

No

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

2. Have you EVER received public assistance in the United States from any source, including the U.S.
Government or any State, county, city or other municipality (other than emergency medical treatment), or are
you likely to receive public assistance in the future?
3. Have you:

4. 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

5. 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:
Yes

No

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

a. Designated as a terrorist organization under section 219 of the Immigration and Nationality Act?
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:

Form I-914 (05/04/12) Y Page 4

PART D. Processing Information

(Continued)
Yes

No

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

7. 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

8. 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

Yes

No

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

10. 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

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?
6. Do you intend to engage in the United States in:

9. Have you EVER been present or nearby when any person was:

11. 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

Form I-914 (05/04/12) Y Page 5

PART D. Processing Information

(Continued)

12. 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

Yes

No

Yes

No

15. Have you EVER received any type of military, paramilitary, or weapons training?

Yes

No

16. 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

17. 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

18. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?

Yes

No

19. 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

20. 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

21. Do you plan to practice polygamy in the United States?

Yes

No

22. Have you entered the United States as a stowaway?

Yes

No

23. 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

13. 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?
14. 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?

Form I-914 (05/04/12) Y 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)

Country of Birth

2.

Middle Name (if any)

Date of Birth (mm/dd/yyyy)

Current Location

Children
a. Family Name (Last Name)

Given Name (First Name)

Country of Birth

b. Family Name (Last Name)

Relationship

Given Name (First Name)

Country of Birth

c. Family Name (Last Name)

Relationship

Given Name (First Name)

Country of Birth

Relationship

Middle Name (if any)

Date of Birth (mm/dd/yyyy)

Current Location

Middle Name (if any)

Date of Birth (mm/dd/yyyy)

Current Location

Middle Name (if any)

Date of Birth (mm/dd/yyyy)

Current Location

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.

PART F. Attestation, Release, and Signature
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 U.S. Citizenship and Immigration Services (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 or prosecuting 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).
Form I-914 (05/04/12) Y Page 7

PART F. Attestation, Release, and Signature

(Continued)

Applicant's Statement (Check one):
I can read and understand English, and I have read and understand each and every question and instruction on this form, as well
as my answer to each question.
Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the
language, a language in which I am fluent, by the person named in Interpreter's Statement and
Signature. I understand each and every question and instruction on this form, as well as my answer to each question.
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this application is
all true and correct. I certify also that I have not withheld any information that would affect the outcome of this application.
Signature of Applicant (the Person in Part A)

Date (mm/dd/yyyy)

PART G. Preparer and/or Interpreter Certification (To be completed and signed if form is prepared by a person
other than the applicant)

Preparer's Statement and Signature (if applicable)
I declare that I prepared this application at the request of the above person, and it is based on all information of which I have
knowledge. I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative: In the event of a Request for Evidence, may USCIS contact you by fax or e-mail?
Preparer's Signature

Preparer's Printed Name

Yes

No

Date (mm/dd/yyyy)

Preparer's Firm Name (if applicable)

Preparer's Address
Daytime Phone Number (with area code)

Fax Number (if any)

E-Mail Address (if any)

Interpreter's Statement and Signature (if applicable)
I certify that I am fluent in English and the below-mentioned language.
Language Used (language in which applicant is fluent):
I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as
well as the answer to each question.
Interpreter's Signature

Printed Name

Date (mm/dd/yyyy)
Telephone Number (with area code)

Form I-914 (05/04/12) Y Page 8

PART H. Checklist
I completely filled out and signed the form.
I have attached evidence that:
a. I am or have been a victim of a severe form of trafficking;
b. 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;
c. I am cooperating with Federal, State, or local law enforcement authorities in the investigation or prosecution of the traffickers
(unless under age 18); and
d. I would suffer extreme hardship involving unusual and severe harm upon removal from the United States.
I have included three photographs of myself.

If I am applying for one or more family members:
I have completed 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. My relationship to the family member for whom I am applying;
b. My age, if I am applying for my parent or unmarried sibling under the age of 18;
c. My child's age, if I am applying for my child; and
d. My sibling's age, if I am applying for my unmarried sibling; and
I have included three photographs of each family member for whom I am now applying.
I have included Form I-765, Application for Employment Authorization, if I am requesting employment authorization for my
family member, along with fee or request for fee waiver.

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 (05/04/12) Y Page 9