Form I-918 Form I-918 Petition for U Nonimmigrant

USCIS
Form I-918

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

Remarks

For
USCIS
Use
Only

OMB No. 1615-0104
Expires 04/30/2021

Action Block

Receipt

DRAFT
NOT FOR
PRODUCTION
05/19/2020

Validity Dates (mm/dd/yyyy) Wait Listed
U.S.
/
/
/
Embassy From:
Consulate To:
/
/
/
Stamp Number

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 is
attached.

Date (mm/dd/yyyy)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black or blue ink.

Part 1. Information About You (Person filing this
petition as a victim)

Safe Mailing Address (if other than Home Address)

4.a. In Care Of Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

4.b. Street Number
and Name

1.c. Middle Name

4.c.

Other Names Used (Include maiden name, nicknames, and
aliases, if applicable)

4.d. City or Town

Apt.

Ste.

4.e. State

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Flr.

4.f.

ZIP Code

4.g. Province

4.h. Postal Code

2.c. Middle Name

4.i.

Home Address

(USPS ZIP Code Lookup)

3.a. Street Number
and Name
3.b.

Apt.

Country

Other Information

Ste.

Flr.

5.

Alien Registration Number (A-Number) (if any)
► A-

3.c. City or Town
6.
3.d. State
3.f.

Province

U.S. Social Security Number (if any)

3.e. ZIP Code

►
7.

USCIS Online Account Number (if any)
►

3.g. Postal Code
3.h. Country

8.

Marital Status
Single

Form I-918 04/24/19

Married

Divorced

Widowed

Page 1 of 11

Part 1. Information About You (continued)
9.

Gender

10.

Date of Birth (mm/dd/yyyy)

11.

Country of Birth

12.

Male

Female

If you need extra space to complete Part 2., use the space
provided in Part 9. Additional Information.
Select "Yes" or "No," as appropriate, for each of the following
questions.
1.

I am a victim of criminal activity listed in the INA at
section 101(a)(15)(U)(iii).
Yes
No

2.

I have suffered substantial physical or mental abuse as a
result of having been a victim of this criminal activity.

Country of Citizenship or Nationality

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Yes

13.

Form I-94 Arrival-Departure Record Number
►

14.

Passport Number

15.

Travel Document Number

16.

Country of Issuance for Passport or Travel Document

17.

Date of Issuance for Passport or Travel Document
(mm/dd/yyyy)

18.

Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

Place and Date of Last Entry into the United States and Date
Authorized Stay Expired
19.a. City or Town
19.b. State

3.

I possess information concerning the criminal activity of
which I was a victim.
Yes
No

4.

I am submitting Form I-918, Supplement B, U
Nonimmigrant Status Certification, from a certifying
official.
Yes
No

5.

The crime of which I am a victim occurred in the United
States (including Indian country and military installations)
or violated the laws of the United States.

6.

I am under 16 years of age.

No

Yes

No

Yes

No

If you answered "Yes," select the type of proceedings. If you
were in proceedings in the past and are no longer in proceedings,
provide the date of action. If you are currently in proceedings,
type or print “Current” in the appropriate date field. Select all
applicable boxes. Use the space provided in Part 9. Additional
Information to provide an explanation.

Date of Last Entry into the United States
(mm/dd/yyyy)

7.b.

Removal Proceedings
Removal Date (mm/dd/yyyy)

21.

Date Authorized Stay Expired (mm/dd/yyyy)

7.c.

Exclusion Proceedings
Exclusion Date (mm/dd/yyyy)

22.

Current Immigration Status

7.d.

Deportation Proceedings
Deportation Date (mm/dd/yyyy)

7.e.

Rescission Proceedings
Rescission Date (mm/dd/yyyy)

7.f.

Judicial Proceedings
Judicial Date (mm/dd/yyyy)

Part 2. Additional Information About You

Form I-918 04/24/19

Yes

7.a. I was or am in immigration proceedings.

20.

Answering “Yes” to the following questions below requires
explanations and supporting documentation. Attach relevant
documents in support of your claims that you are a victim of
criminal activity listed in the Immigration and Nationality Act
(INA) section 101(a)(15)(U)(iii). You must also attach a
personal narrative statement describing the criminal activity of
which you are a victim. If you are only petitioning for U
derivative status for qualifying family members subsequent to
your (the principal petitioner) initial filing, you are not required
to submit evidence supporting the original petition with the new
Form I-918.

No

Page 2 of 11

Part 2. Additional Information About You
(continued)
Provide the date of entry, place of entry, and status under
which you entered the United States for each entry during
the five years preceding the filing of this petition.
8.a. Date of Entry (mm/dd/yyyy)
Place of Entry into the United States

11.c. State
11.d. Country

Safe Foreign Address Where You Want Notification Sent
(if other than U.S. Consulate, Pre-Flight Inspection, or
Port-of-Entry)

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8.b. City or Town
8.c. State

11.b. City or Town

12.a. Street Number
and Name

8.d. Status at the Time of Entry (for example, F-1 student,
B-2 tourist, entered without inspection)

12.b.

Apt.

Ste.

Flr.

12.c. City or Town
12.d. Province

9.a. Date of Entry (mm/dd/yyyy)

12.e. Postal Code

Place of Entry into the United States

12.f. Country

9.b. City or Town
9.c. State

Part 3. Biographic Information

9.d. Status at the Time of Entry (for example, F-1 student,
B-2 tourist, entered without inspection)

10.a. Date of Entry (mm/dd/yyyy)

1.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

2.

Race (Select all applicable boxes)
White
Asian
Black or African American

Place of Entry into the United States
10.b. City or Town
10.c. State

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

10.d. Status at the Time of Entry (for example, F-1 student,
B-2 tourist, entered without inspection)

If you are outside of the United States, provide the U.S.
Consulate or inspection facility or a safe foreign mailing
address you want notified if this petition is approved.

3.

Height

4.

Weight

5.

Eye Color (Select only one box)

11.a. Type of Office (Select only one box):
U.S. Consulate
Port-of-Entry

Form I-918 04/24/19

Pre-Flight Inspection

6.

Feet

Inches
Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red
Unknown/Other

Page 3 of 11

Information About Arrests, Citations, Detentions, or Charges

Part 4. Processing Information
Answer the following questions about yourself. For the
purposes of this petition, you must answer "Yes" to the
following questions, if applicable, 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.
NOTE: If you answer “Yes” to ANY question in Part 4.,
provide an explanation in the space provided in Part 9.
Additional Information.

If you answered “Yes” to any of the above questions, respond to
the questions below to provide additional details. If you need
extra space, use the space provided in Part 9. Additional
Information.
2.a

Why were you arrested, cited, detained, or charged?

2.b. Date of arrest, citation, detention, or charge (mm/dd/yyyy)

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NOTE: Answering "Yes" does not necessarily mean that U.S.
Citizenship and Immigration Services (USCIS) will deny your
Petition for U Nonimmigrant Status.

Where were you arrested, cited, detained, or charged?

Have you EVER:

2.d. State

1.a. Committed a crime or offense for which you have not
been arrested?
Yes
No

2.e. Country

1.b. Been arrested, cited, or detained by any law enforcement
officer (including Department of Homeland Security
(DHS), former Immigration and Naturalization Service
(INS), and military officers) for any reason?
Yes

3.a

Why were you arrested, cited, detained, or charged?

3.b. Date of arrest, citation, detention, or charge (mm/dd/yyyy)

No

1.e. Been placed in an alternative sentencing or a rehabilitative
program (for example, diversion, deferred prosecution,
withheld adjudication, deferred adjudication)?
Yes
No
1.f.

Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)

No

1.d. Been convicted of a crime or offense (even if the
violation was subsequently expunged or pardoned)?
Yes

2.f.

No

1.c. Been charged with committing any crime or offense?
Yes

2.c. City or Town

Received a suspended sentence, been placed on probation,
or been paroled?
Yes
No

Where were you arrested, cited, detained, or charged?
3.c. City or Town
3.d. State

3.e. Country

3.f.
1.g. Been in jail or prison?

Yes

No

Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)

1.h. Been the beneficiary of a pardon, amnesty, rehabilitation,
or other act of clemency or similar action?
Yes
1.i.

No

Exercised diplomatic immunity to avoid prosecution for a
criminal offense in the United States?
Yes
No

Have you EVER:
4.a. Engaged in, or do you intend to engage in, prostitution or
procurement of prostitution?
Yes
No
4.b. Engaged in any unlawful commercialized vice, including,
but not limited to, illegal gambling?
Yes
No
4.c. Knowingly encouraged, induced, assisted, abetted, or
aided any alien to try to enter the United States illegally?
Yes

No

4.d. Illicitly trafficked in any controlled substance or knowingly
assisted, abetted, or colluded in the illicit trafficking of any
controlled substance?
Yes
No
Form I-918 04/24/19

Page 4 of 11

6.g. Soliciting money or members or otherwise providing
material support to a terrorist organization?

Part 4. Processing Information (continued)
Have you EVER committed, planned or prepared, participated
in, threatened to, attempted to, conspired to commit, gathered
information for, or solicited funds for any of the following:
5.a. Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
Yes
No
5.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

Yes

No

Yes

No

Do you intend to engage in the United States in:
7.a. Espionage?

7.b. Any unlawful activity, or any activity the purpose of
which is in opposition to, or the control, or overthrow of
the government of the United States?
Yes
No

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5.c. Assassination?

Yes

7.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

No

5.d. The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to
cause substantial damage to property?
Yes
No

8.

Have you EVER been or do you continue to be a member
of the Communist or other totalitarian party, except when
membership was involuntary?
No
Yes

5.e. The use of any biological agent, chemical agent, 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

9.

Have you EVER, 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, 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?

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 any other group of two or
more individuals, whether organized or not, which has been
designated as, or has engaged in or has a subgroup which has
been designated as, or has engaged in:
6.a. A terrorist organization under section 219 of the INA?
Yes

No

6.b. Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
Yes
No

6.c. 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
6.d. Assassination?

Yes

No

6.e. The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to cause
substantial damage to property?
Yes
No
6.f.

The use of any biological agent, chemical agent, 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-918 04/24/19

Yes

No

Have you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:
10.a. Acts involving torture or genocide?

Yes

No

10.b. Killing any person?

Yes

No

10.c. Intentionally and severely injuring any person?
Yes

No

10.d. Engaging in any kind of sexual conduct or relations with
any person who was being forced or threatened?
Yes

No

10.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
10.f. The persecution of any person because of race, religion,
national origin, membership in a particular social group,
or political opinion?
Yes
No
10.g. Displacing or moving any person from their residence by
force, threat of force, compulsion, or duress?
Yes

No

NOTE: If you answered "Yes" to any question in Item
Numbers 10.a. - 10.g., please describe the circumstances in
Part 9. Additional Information.

Page 5 of 11

Part 4. Processing Information (continued)

Have you EVER:

11.

15.a. Recruited, enlisted, conscripted, or used any person under
15 years of age to serve in or help an armed force or group?

Have you EVER advocated that another person commit
any of the acts described in the preceding question, urged,
or encouraged another person, to commit such acts?
Yes

No

Have you EVER been present or nearby when any person was:
12.a. Intentionally killed, tortured, beaten, or injured?

Yes

15.b. Used any person under 15 years of age to take part in
hostilities, or to help or provide services to people in
combat?
Yes
No
16.

Are you NOW in removal, exclusion, rescission, or
deportation proceedings?
Yes
No

17.

Have you EVER had removal, exclusion, rescission, or
deportation proceedings initiated against you?

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Yes

No

12.b. Displaced or moved from his or her residence by force,
compulsion, or duress?
Yes
No

12.c. In any way compelled or forced to engage in any kind of
sexual contact or relations?
Yes
No

No

Yes

No

18.

Have you EVER been removed, excluded, or deported
from the United States?
Yes
No

19.

Have you EVER been ordered to be removed, excluded,
or deported from the United States?
Yes
No

20.

Have you EVER been denied a visa or denied admission
to the United States?
Yes
No

21.

13.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

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

22.

13.c. Served in, been a member of, assisted in, or participated
in any group, unit, or organization of any kind in which
you or other persons transported, possessed, or used any
type of weapon?
Yes
No

Are you NOW under a final order or civil penalty for
violating section 274C of the INA (producing and/or
using false documentation to unlawfully satisfy a
requirement of the INA)?
Yes
No

23.

NOTE: If you answered "Yes" to any question in Item
Numbers 13.a. - 13.c., please describe the circumstances in
Part 9. Additional Information.

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

24.

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

Have you EVER:

13.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or other insurgent organization?
Yes

No

Have you EVER:

14.a. Received any type of military, paramilitary, or weapons
training?
Yes
No
14.b. 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
14.c. 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
NOTE: If you answered "Yes" to any question in Item
Numbers 14.a. - 14.c., please describe the circumstances in
Part 9. Additional Information.

Form I-918 04/24/19

Yes

No

25.

Have you EVER been a J nonimmigrant exchange visitor
who was subject to the 2-year foreign residence
requirement and not yet complied with that requirement
or obtained a waiver of such?
Yes
No

26.

Have you EVER detained, retained, or withheld the
custody of a child, having a lawful claim to United States
citizenship, outside the United States from a United States
citizen granted custody?
Yes
No

27.

Do you plan to practice polygamy in the United States?
Yes

No

Page 6 of 11

Part 4. Processing Information (continued)
28.

Have you EVER entered the United States as a stowaway?
Yes

No

29.a. Do you NOW have a communicable disease of public
health significance?
Yes
No
29.b. Do you NOW have or have you EVER 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

11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
11.c. Middle Name
12.

Date of Birth (mm/dd/yyyy)

13.

Country of Birth

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29.c. Are you NOW or have you EVER been a drug abuser or
drug addict?
Yes
No

Part 5. Information About Your Spouse and/or
Children
If you need extra space to complete Part 5., use the space
provided in Part 9. Additional Information.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

4.

Relationship

5.

Current Location

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Middle Name
7.

Date of Birth (mm/dd/yyyy)

8.

Country of Birth

9.

Relationship

10.

Current Location

Form I-918 04/24/19

14.

Relationship

15.

Current Location

16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)

16.c. Middle Name
17.

Date of Birth (mm/dd/yyyy)

18.

Country of Birth

19.

Relationship

20.

Current Location

21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)

21.c. Middle Name
22.

Date of Birth (mm/dd/yyyy)

23.

Country of Birth

24.

Relationship

25.

Current Location

Page 7 of 11

Part 5. Information About Your Spouse and/or
Children (continued)

Petitioner'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 of my records that USCIS may need
to determine my eligibility for the immigration benefit I seek.

Filing On Behalf of Family Members
26.

I am petitioning for one or more qualifying family
members.
Yes

No

NOTE: If you answered “Yes” to 26., you must
complete and include Supplement A for each family
member for whom you are petitioning.

I further authorize release of information contained in this
petition, in supporting documents, and in my USCIS records to
other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.

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Part 6. Petitioner's Statement, Contact
Information, Declaration, and Signature

I certify, under penalty of perjury, that all of the information in
my petition 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 petition, and
that all of this information is complete, true, and correct.

NOTE: Read the Penalties section of the Form I-918
Instructions before completing this part.

Petitioner's Statement

Petitioner's Signature

NOTE: Select the box for either 1.a. or 1.b. If applicable,
select the box for 2.
1.a.

1.b.

6.a. Petitioner's Signature

I can read and understand English, and I have read and
understand every question and instruction on this
petition and my answer to every question.

The interpreter named in Part 7. read to me every
question and instruction on this petition and my answer
to every question in
,

a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 8.,

,

prepared this petition for me based only upon
information I provided or authorized.

6.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL PETITIONERS: If you do not completely
fill out this petition or fail to submit required documents listed
in the Instructions, USCIS may deny your petition.
NOTE: A parent or legal guardian may sign for a person who
is less than 14 years of age. A legal guardian may sign for a
mentally incompetent person.

Part 7. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Petitioner's Contact Information

Interpreter's Full Name

3.

Petitioner's Daytime Telephone Number

1.a. Interpreter's Family Name (Last Name)

4.

Petitioner's Mobile Telephone Number (if any)

1.b. Interpreter's Given Name (First Name)

5.

Petitioner's Email Address (if any)

2.

Form I-918 04/24/19

Interpreter's Business or Organization Name (if any)

Page 8 of 11

Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner
Provide the following information about the preparer.

Preparer's Full Name

Ste.

Flr.

1.a. Preparer's Family Name (Last Name)

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3.c. City or Town
3.d. State
3.f.

Province

3.e. ZIP Code

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

3.g. Postal Code
3.h. Country

Preparer's Mailing Address

Interpreter's Contact Information

3.a. Street Number
and Name
3.b.

4.

Apt.

Ste.

Flr.

Interpreter's Daytime Telephone Number

3.c. City or Town

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

,
which is the same language specified in Part 6., 1.b., and I have
read to this petitioner in the identified language every question
and instruction on this petition and his or her answer to every
question. The petitioner informed me that he or she understands
every instruction, question, and answer on the petition,
including the Petitioner's Declaration and Certification, and
has verified the accuracy of every answer.

3.h. Country

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Signature
7.a. Interpreter's Signature (sign in ink)

7.b. Date of Signature (mm/dd/yyyy)

Form I-918 04/24/19

Page 9 of 11

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner (continued)
Preparer's Statement
7.a.

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

7.b.

I am an attorney or accredited representative and my
representation of the petitioner in this case
extends
does not extend beyond the preparation
of this petition.

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NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this petition, you may be obliged to
submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this petition.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this petition at the request of the petitioner. The
petitioner then reviewed this completed petition and informed
me that he or she understands all of the information contained
in, and submitted with, his or her petition, including the
Petitioner's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
petition based only on information that the petitioner provided
to me or authorized me to obtain or use.

Preparer's Signature

8.a. Preparer's Signature (sign in ink)

8.b. Date of Signature (mm/dd/yyyy)

Form I-918 04/24/19

Page 10 of 11

5.a. Page Number

Part 9. Additional Information
If you need extra space to provide any additional information
within this petition, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this petition or attach a separate sheet
of paper. Include your name and A-Number (if any) at the top
of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
NOT FOR
PRODUCTION
05/19/2020

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-918 04/24/19

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.d.

Page 11 of 11