Form I-914 Application for T Nonimmigrant Status; Application for I

USCIS
Form I-914

Application for T Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0099
Expires 01/31/2019

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.

Receipt

Returned

PART A. Purpose for Filing the Application

Date
Check all that apply:
I am filing for T-1 nonimmigrant status and have not previously filed for such
status.

Date
Resubmitted

DRAFT
Not for
Production
08/29/2018

I am filing for T-1 nonimmigrant status and have previously filed for such status.
Receipt Number (begins with EAC)

I have received T-1 status and am applying to bring family members 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)

Middle Name (if any)

Date
Date

Reloc Sent

Date
Date

Reloc Rec'd

Date
Date

Other Names Used (Include maiden name/nickname)

Validity Dates

Home Address - Street Number and Name

Apt. Number

From:
To:

City

State/Province

Zip/Postal Code

Remarks

Safe Mailing Address (if other than above) - Street Number and Name
C/O (in care of):
City

State/Province

Apt. Number

Zip/Postal Code

Conditional Approval

Home Telephone Number
(with area code)

Safe Daytime Phone Number
(with area code)

Stamp #

Date

Action Block
E-Mail Address (optional)

A-Number (if any)

U.S. Social Security Number (if any)
Marital Status:
Single/Never Married
Date of Birth (mm/dd/yyyy)
Passport Number

Gender
Male
Married

Country of Birth
Place of Issuance

Place of Last Entry
Form I-94 Number (Arrival-Departure Record)

Form I-914 02/27/17 Y

Female
Divorced

Widowed

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

To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the applicant.
ATTY State
License #

Page 1

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. You must 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 require 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).

DRAFT
Not for
Production
08/29/2018

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, 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 "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

Circumstances:

Address

Phone Number

Case Number

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, or am unable to cooperate with such requests due to
physical or psychological trauma. (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

Form I-914 02/27/17 Y

Place of Entry

Status

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.)

DRAFT
Not for
Production
08/29/2018

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?

Form I-914 02/27/17 Y

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.)

Page 3

PART D. Processing Information (continued)
2.

3.

4.

Have you:
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

DRAFT
Not for
Production
08/29/2018

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

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

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

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

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 02/27/17 Y

Page 4

PART D. Processing Information (continued)
5.

Do you intend to engage in the United States in:
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

6.

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

7.

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

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

c. In any way compelled or forced to engage in any kind of sexual contact or relations?

Yes

No

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

9.

DRAFT
Not for
Production
08/29/2018

10. 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

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

11. Have you EVER:

Form I-914 02/27/17 Y

Page 5

PART D. Processing Information (continued)
12. 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?

Yes

No

13. 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?

Yes

No

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

Yes

No

15. 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

16. 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

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

Yes

No

18. 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

19. 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

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

Yes

No

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

Yes

No

22. 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

DRAFT
Not for
Production
08/29/2018

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)

Country of Birth

Form I-914 02/27/17 Y

Given Name (First Name)

Middle Name (if any)

Date of Birth (mm/dd/yyyy)

Current Location

Page 6

PART E. Information About Your Family Members (continued)
Children

2.

a. Family Name (Last Name)

Given Name (First Name)

Country of Birth

Middle Name (if any)

Relationship

Date of Birth (mm/dd/yyyy)

Current Location

DRAFT
Not for
Production
08/29/2018

b. Family Name (Last Name)

Given Name (First Name)

Country of Birth

c. Family Name (Last Name)

Middle Name (if any)

Relationship

Given Name (First Name)

Country of Birth

Date of Birth (mm/dd/yyyy)

Current Location

Middle Name (if any)

Relationship

Date of Birth (mm/dd/yyyy)

Current Location

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 to have join you in the United States, and attach it to this application.

PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part.

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 G. read to me every question and instruction on this application and my answer to every
question in
,
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 H.,
prepared this application for me based only upon information I provided or authorized.

Form I-914 02/27/17 Y

,

Page 7

PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

DRAFT
Not for
Production
08/29/2018

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 (sign in ink)

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.

Form I-914 02/27/17 Y

Page 8

PART G. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

DRAFT
Not for
Production
08/29/2018

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and
, which is the same language specified in Part F., 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 (sign in ink)

Form I-914 02/27/17 Y

Date of Signature (mm/dd/yyyy)

Page 9

PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

DRAFT
Not for
Production
08/29/2018

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case
does not extend beyond the preparation of this application.
extends
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28,
Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.

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 (sign in ink)

Form I-914 02/27/17 Y

Date of Signature (mm/dd/yyyy)

Page 10