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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 - 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
member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be
completed by the principal applicant.
For USCIS Use Only
Returned
Receipt
Date
Date
Resubmitted
PART A. Family Member Relationship to You (the principal)
The family member that I am filing for is my: (Check one)
Husband/Wife
Child
Parent
Unmarried Sibling Under Age 18
PART B. General Information About You (the principal)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Date
Date
Reloc Sent
Date
Date of Birth (mm/dd/yyyy)
A # (if any)
Date
Reloc Rec'd
Status of your Form I-914, Application for T Nonimmigrant Status: (Check one)
Date
Filing this Form I-914, Supplement A, concurrently
Pending
Approved
Date
Validity Dates
PART C. Information About Your Family Member (the derivative)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
From:
To:
Remarks
Other Names Used (include maiden name/nickname)
Date of Birth (mm/dd/yyyy) Country of Birth
Country of Citizenship
Residence or Intended Residence in the U.S. - Street Number and Name
City
State
Apt. #
Conditional Approval
Zip Code
Stamp #
Safe Mailing Address (if other than above) - Street Number and Name
Date
Action Block
Apt. #
C/O (in care of):
City
Home Telephone #
(with area code)
A # (if any)
State/Province
Safe Daytime Phone #
(with area code)
Zip/Postal Code
I-94 # (Arrival-Departure
Document)
U.S. Social Security # (if any) Gender
Male
Marital Status:
Married
To Be Completed by
Attorney or Representative, if any
Female
Fill in box if G-28 is attached to
represent the applicant.
ATTY State License #
Single/Never Married
Divorced
Widowed
Form I-914, Supplement A (Rev. 05/04/12) Y
PART C. Information About Your Family Member
(Continued)
1. Give the following information about your family member if he or she is currently in the United States.
Place of Last Entry
Passport #
Date of Last Entry (mm/dd/yyyy)
Current Immigration Status
Place of Issuance
Date of Issue (mm/dd/yyyy)
2. Give the following information about your family member if he or she has previously traveled to the United States.
Place of Entry
Date of Entry
(mm/dd/yyyy)
Date Authorized Stay
Expired (mm/dd/yyyy)
Immigration Status
3. If your family member was previously married, list names of prior spouses and dates of termination of marriage. Documents such
as divorce decrees or death certificates must be attached.
Name of Former Spouse(s)
Date Marriage Ended
(mm/dd/yyyy)
Where and How Marriage Ended
4. If your family member is outside the United States, indicate the U.S. consulate or inspection facility you want notified if this
application is approved.
Type of Office (Check one):
Consulate
Pre-Flight Inspection
Office Address (City)
Port of Entry
U.S. State or Foreign Country
Foreign Address Where You Want Notification Sent
Yes
5. Has your family member ever been in immigration proceedings?
No
If "Yes," what type of proceedings? (Check all that apply)
Removal Date
(mm/dd/yyyy)
Exclusion Date
(mm/dd/yyyy)
Deportation Date
(mm/dd/yyyy)
Rescission Date
(mm/dd/yyyy)
Judicial Date
(mm/dd/yyyy)
Form I-914, Supplement A (Rev. 05/04/12) Y Page 2
PART C. Information About Your Family Member
(Continued)
6. Is your family member requesting an Employment Authorization Document? (If "Yes," submit Form I-765,
Application for Employment Authorization Document, separately.)
Yes
No
NOTE: If your family member is living outside the United States, he or she is not eligible to receive employment authorization
until he or she is lawfully admitted to the United States. Do not file Form I-765 for a family member living outside the United
States.
PART D. Processing Information
Answer the following questions about your family member. For the purposes of this application, if applicable, you must answer “Yes”
to the following questions even if the records were sealed or otherwise cleared or if anyone, including a judge, law enforcement
officer, or attorney, told you that your family member no longer has a record. (If your answer is "Yes" to any one of these questions,
explain on a separate sheet 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 filing EVER:
a. Committed a crime or offense for which he or she has 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 the answer is “Yes” to any of the above questions, complete the following table. If you need more space, use a separate sheet of
paper.
Why was the family member for whom Date of arrest,
you are filing arrested, cited, detained, citation,
or charged?
detention, charge
(mm/dd/yyyy)
Where was the family member
for whom you are filing arrested,
cited, detained, or charged?
(City, State, Country)
Outcome or disposition
(e.g., no charges filed,
charges dismissed, jail,
probation, etc.)
Form I-914, Supplement A (Rev. 05/04/12) Y Page 3
PART D. Processing Information
(Continued)
2. Has the family member for whom you are filing 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 is he or she likely to receive public assistance in the future?
Yes
No
a. Engaged in prostitution or procurement of prostitution or does he or she 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. Has the family member for whom you are filing:
4. Has the family member for whom you are filing 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. Has the family member for whom you are filing 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
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, Supplement A (Rev. 05/04/12) Y Page 4
PART D. Processing Information
(Continued)
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
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. Has the family member for whom you are filing EVER been or does he or she continue to be a member of the
Communist or other totalitarian party, except when membership was involuntary?
Yes
No
8. Has the family member for whom you are filing, 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
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
Yes
No
b. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the family
member for whom your are filing?
Yes
No
c. Has the family member for whom your are filing EVER been removed, excluded, or deported from the
United States?
Yes
No
d. Has the family member for whom your are filing EVER been ordered to be removed, excluded, or
deported from the United States?
Yes
No
e. Has the family member for whom your are filing 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. Has the family member for whom your are filing EVER been granted voluntary departure by an
immigration officer or an immigration judge and failed to depart within the allotted time?
Yes
No
6. Does the family member for whom you are filing intend to engage in the United States in:
9. Has the family member for whom you are filing EVER been present or nearby when any person was:
10. a. Are removal, exclusion, rescission, or deportation proceedings pending against the family member for
whom your are filing?
Form I-914, Supplement A (Rev. 05/04/12) Y Page 5
PART D. Processing Information
(Continued)
11. Has the family member for whom you are filing (or has any member of his or her family) 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
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
13. Has the family member for whom you are filing EVER been a member of, assisted in, or participated in any
group, unit, or organization of any kind in which he or she or any other persons used any type of weapon
against any person or threatened to do so?
Yes
No
14. Has the family member for whom you are filing EVER assisted or participated in selling or providing
weapons to any person who to his or her knowledge used them against another person, or in transporting
weapons to any person who to his or her knowledge used them against another person?
Yes
No
15. Has the family member for whom you are filing EVER received any type of military, paramilitary, or
weapons training?
Yes
No
16. Is the family member for whom you are filing 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. Has the family member for whom you are filing 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. Has the family member for whom you are filing EVER left the United States to avoid being drafted into the
U.S. Armed Forces?
Yes
No
19. Has the family member for whom you are filing 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. Has the family member for whom you are filing 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
12. Has the family member for whom you are filing EVER:
Form I-914, Supplement A (Rev. 05/04/12) Y Page 6
PART D. Processing Information
(Continued)
21. Does the family member for whom you are filing plan to practice polygamy in the United States?
Yes
No
22. Did the family member for whom you are filing enter the United States as a stowaway?
Yes
No
23. a. Does the family member for whom you are filing have a communicable disease of public health
significance?
Yes
No
b. Does the family member for whom you are filing have or has he or she 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 themselves or others?
Yes
No
c. Is the family member for whom you are filing now or has he or she been a drug abuser or drug addict?
Yes
No
PART E. Attestation, Release, and Signature
After reading the information regarding penalties in the instructions, you, the principal, must sign below. Your family
member for whom you are applying must also 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.
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 for the family member for whom I am applying, 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).
Principal Applicant's Statement and Signature (Choose one of the following):
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.
Principal Applicant's Signature (you)
Date (mm/dd/yyyy)
Signature of Derivative (your family member if physically present in the United States)
Date (mm/dd/yyyy)
Form I-914, Supplement A (Rev. 05/04/12) Y Page 7
PART F. Preparer and/or Interpreter Certification and Signature
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
Yes
No
Date (mm/dd/yyyy)
Preparer's Printed Name
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)
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 (Rev. 05/04/12) Y Page 8
| File Type | application/pdf |
| File Modified | 2012-07-25 |
| File Created | 2009-03-30 |