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pdfSupplement A, Application for Family
Member of T-1 Recipient
USCIS
Form I-914
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0099
Expires 04/30/2021
START HERE - Type or print. Use black ink. See Instructions for information about
For USCIS Use Only
eligibility and how to complete and file this application. The recipient of the T
Returned
Receipt
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
Date
completed by the principal applicant.
Date
PART A. Family Member Relationship to You (the principal)
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The family member that I am filing for is my: (Check one)
Husband/Wife
Child
Parent
Resubmitted
Date
Unmarried Sibling Under 18 Years of Age
Date
Reloc Sent
PART B. Family Member Relationship to Your Derivative
Date
The family member I am filing for is the adult or minor child of my derivative (my
grandchild, my spouse's 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
Date
Reloc Rec'd
Date
Minor Child
Date
Validity Dates
PART C. Biographic Information
1.
Ethnicity (Select only one box)
2.
Race (Select all applicable boxes)
Hispanic or Latino
Asian
Native Hawaiian or Other Pacific Islander
Height Feet
5.
Eye Color (Select only one box)
6.
Inches
Black or African American
Gray
Blue
Brown
Maroon
Pink
Unknown/Other
Weight
Green
Pounds
Hazel
Conditional Approval
Hair Color (Select only one box)
Sandy
White
Black
Remarks
White
4.
Black
Bald (No hair)
From:
To:
American Indian or Alaska Native
3.
Not Hispanic or Latino
Stamp #
Blond
Brown
Gray
Red
Date
Action Block
Unknown/Other
PART D. General Information About You (the principal)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Date of Birth (mm/dd/yyyy) A-Number (if any)
To Be Completed by
Attorney or Representative, if any
Status of your Form I-914, Application for T Nonimmigrant Status: (Check one)
Filing this Form I-914, Supplement A, concurrently
Pending
Approved
Form I-914, Supplement A 04/15/19
Fill in box if G-28 is attached to
represent the applicant.
ATTY State
License #
Page 1
PART E. Information About Your Family Member (the derivative)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Other Names Used (include maiden name/nickname)
Residence or Intended Residence in the U.S. - Street Number and Name
City
Apt. Number
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State
Safe Mailing Address (if other than above) - Street Number and Name
C/O (in care of):
City
State/Province
Home Telephone Number
(with area code)
Safe Daytime Telephone
Number (with area code)
A-Number (if any)
U.S. Social Security Number (if any)
Marital Status:
Single/Never Married
Married
Apt. Number
ZIP/Postal Code
E-mail Address
(optional)
Gender
Male
Divorced
Date of Birth (mm/dd/yyyy) Country of Birth
Passport Number
ZIP Code
Female
Widowed
Country of Citizenship
Place of Issuance
Date of Issue (mm/dd/yyyy)
Give the following information about your family member if he or she is currently in the United States.
Place of Last Entry
I-94 Number (Arrival-Departure Document)
Date of Last Entry (mm/dd/yyyy)
Current Immigration Status
Give the following information about your family member if he or she has previously traveled to the United States.
Place of Entry
Form I-914, Supplement A 04/15/19
Date of Entry
(mm/dd/yyyy)
Date Authorized Stay
Expired (mm/dd/yyyy)
Immigration Status
Page 2
PART E. Information About Your Family Member (the derivative) (continued)
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
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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):
Office Address (City)
Consulate
Pre-Flight Inspection
Port of Entry
U.S. State or Foreign Country
Foreign Address Where You Want Notification Sent
Has your family member ever been in immigration proceedings?
Yes
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)
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.)
Judicial Date
(mm/dd/yyyy)
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 F. 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
Form I-914, Supplement A 04/15/19
Page 3
PART F. Processing Information (continued)
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.
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Why was the family member for whom
Date of arrest,
Where was the family member
you are filing arrested, cited, detained,
citation,
for whom you are filing arrested,
or charged?
detention, charge
cited, detained, or charged?
(mm/dd/yyyy)
(City, State, Country)
2.
3.
Outcome or disposition
(e.g., no charges filed,
charges dismissed, jail,
probation, etc.)
Has the family member for whom you are filing:
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
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
Form I-914, Supplement A 04/15/19
Page 4
PART F. Processing Information (continued)
4.
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:
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
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.
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
7.
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
8.
Has the family member for whom you are filing 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 the family member for
whom your are filing?
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
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:
5.
Does the family member for whom you are filing intend to engage in the United States in:
a. Espionage?
9.
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Form I-914, Supplement A 04/15/19
Page 5
PART F. Processing Information (continued)
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
10. 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
12. 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
13. 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
14. Has the family member for whom you are filing EVER received any type of military, paramilitary, or
weapons training?
Yes
No
15. 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
16. 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
17. 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
18. 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
19. 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
20. Does the family member for whom you are filing plan to practice polygamy in the United States?
Yes
No
21. Did the family member for whom you are filing enter the United States as a stowaway?
Yes
No
22. 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 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
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11. Has the family member for whom you are filing EVER:
Form I-914, Supplement A 04/15/19
Page 6
PART G. 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 H. read to me every question and instruction on this application and my answer to every
question in
,
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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 I.,
prepared this application for me based only upon information I provided or authorized.
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)
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S.
Citizenship and Immigration Services (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 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).
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 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)
Signature of Derivative (your family member if physically present in the United States) (sign in ink)
Date of Signature (mm/dd/yyyy)
Date (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, Supplement A 04/15/19
Page 7
PART H. 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)
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Interpreter's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
ZIP Code
Country
Postal Code
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 G., 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, Supplement A 04/15/19
Date of Signature (mm/dd/yyyy)
Page 8
PART I. 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)
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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, Supplement A 04/15/19
Date of Signature (mm/dd/yyyy)
Page 9
| File Type | application/pdf |
| File Title | Form I-914, Supplement A, Application for Family Member of T-1 Recipient |
| Author | USCIS |
| File Modified | 2020-05-19 |
| File Created | 2020-05-19 |