Table of Changes (Form I-914 Supplement A)

TABLE OF CHANGES – FORM

FORM I-914, Supplement A

Application for Immediate Family Member of T-1 Recipient

OMB Number: 1615-0099

Submission Date 06/18/2013

Reason for Revision: Statutory and regulatory changes have necessitated revisions.

Current Section and Page Number	Current Text	Proposed Text
		[Please remove the barcode from the bottom of all pages.]
Page 1, New Header		Part B. Family Member Relationship to Your Derivative [new heading] The family member that I am filing for is my adult or minor child of my derivative (my child, my grandchild, my step-child, my niece or nephew, or my sibling) who faces a present danger of retaliation as a result of my escape from the severe form of trafficking in persons or my cooperation with law enforcement. Derivative’s Adult or Minor Child
Page 1, Part B. General Information About You (the principal)	Part B. General Information About You (the principal) A # (if any)	Part C. General Information About You (the principal) A-Number (if any)
Page 1, Part C. Information About Your Family Member (the derivative)	Part C. Information About Your Family Member (the derivative) 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 Apt. #/City/State/Zip Code Safe Mailing Address (if other than above) – Street Number and Name\Apt. #\City\State/Province\Zip/Postal Code Home Telephone # (with area code) Safe Daytime Telephone # (with area code) I-94 # (Arrival-Departure Document) A # (if any) U.S. Social Security # (if any) Gender and Marital Status 1. Give the following information about your family member if he or she is currently in the United States. Place of Last Entry/Date of Last Entry/Current Immigration Status 2. Give the following information…. 3. If your family member was…. 4. If your family member is outside… Foreign Address Where You Want Notification Sent 5. Has your family member ever been… 6. Is your family member requesting an Employment Authorization Document? (If “Yes,” submit Form I-765, Application for Employment Authorization Document, separately.) Note: If your family….	Part D. Information About Your Family Member (the derivative) [Data element order Rearranged to Match Form I-914.] 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 Apt. Number/City/State/ZIP Code Safe Mailing Address (if other than above) – Street Number and Name\Apt. Number\City\State/Province\ZIP/Postal Code Home Telephone Number (with area code) Safe Daytime Telephone Number (with area code) E-Mail Address (optional) A-Number (if any) U.S. Social Security Number (if any) Gender and Marital Status Date of Birth (mm/dd/yyyy)/Country of Birth/Country of Citizenship Passport Number/Place of Issuance/Date of Issue (mm/yy/dddd) Give the following information about your family member if he or she is currently in the United States. Place of Last Entry/Date of Last Entry I-94 Number (Arrival-Departure Document) Current Immigration Status Give the following information…. If your family member was…. If your family member is outside… Foreign Address Where You Want Notification Sent Has your family member ever been… Is your family member requesting an Employment Authorization Document? (If “Yes,” submit Form I-765, Application for Employment Authorization Document with Form I-914, Supplement A or separately.) Note: If your family….
Page 3, Part D. Processing Information	Part D. Processing Information	Part E. Processing Information
Page 7, Part E. Attestation, Release, and Signature	Part E. Attestation, Release, and Signature	Part F. Attestation, Release, and Signature
Page 8, Part F. Preparer and/or Interpreter Certification and Signature	Part F. Preparer and/or Interpreter Certification and Signature	Part G. Preparer and/or Interpreter Certification and Signature

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