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

Supplement 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 12/31/2023

START HERE - Type or print in ink. Use black ink. See Instructions for information
For USCIS Use Only
about 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 1. Family Member Relationship to You (the principal)
(Select only one box in either Part 1. or Part 2.)

1.

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Resubmitted

Date

The family member that I am filing for is my:

Date

Husband/Wife

Reloc Sent

Child

Parent

Date

Unmarried Sibling Under 18 Years of Age

Date

Reloc Rec'd

PART 2. Family Member Relationship to Your Derivative
1.

The family member I am filing for is the adult or minor child of one of the family
members listed in Part 1., Item Number 1. 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 and is the adult or minor
(Select only one box in either Part 1. or Part 2.)

Date
Date

Validity Dates

From:
To:

Child of my spouse

Remarks

Child of my child (my grandchild)

Child of my parent (my sibling over 18 years of age)

Child of my unmarried sibling under 18 years of age (my niece or nephew)

PART 3. General Information About You (the principal)
1.

Your Full Legal Name
Family Name (Last Name)

Conditional Approval
Given Name (First Name)

Middle Name (if any )

Stamp #

Date

Action Block
2.

3.

Date of Birth (mm/dd/yyyy)

Alien Registration Number (A-Number)
► A-

4.

Status of your Form I-914, Application for T Nonimmigrant Status: (Select one)
Filing this Form I-914, Supplement A, together
Pending
Approved

To be fully completed by an attorney or
accredited representative, if any.

PART 4. Information About Your Family Member (the derivative)
1.

Your Full Legal Name
Family Name (Last Name)

Given Name (First Name)

Form I-914, Supplement A Edition 12/02/21

Middle Name (if any)

Select this box if Form G-28 is
attached.
Attorney or Accredited Representative
USCIS Online Account Number

Page 1

PART 4. Information About Your Family Member (the derivative) (continued)
2.

Other Names Used
Provide any other names you have used since birth, including aliases, maiden names, and nicknames. If you need extra space to
complete this section, use the space provided in Part 9. Additional Information.
Family Name (Last Name)

3.

4.

Given Name (First Name)

Middle Name (if any)

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U.S. Physical Address or Intended Physical Address

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Safe U.S. Mailing Address

If you do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home
address, you may provide an alternate safe mailing address.
In Care Of Name

5.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

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

6.

USCIS Online Account Number
►

8.

Gender or Sex

► A7.

U.S. Social Security Number (SSN) (if any)
►

9.

Male

Female

ZIP Code

Other

Marital Status
Single/Never Married

Married

Divorced

Widowed

Annulled

10. 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. If you need extra space to complete this section,
use the space provided in Part 9. Additional Information.
A. Name of Former Spouse
Family Name (Last Name)

Given Name (First Name)

Middle Name

B. Date Marriage Ended (mm/dd/yyyy)
(mm/dd/yyyy)

Form I-914, Supplement A Edition 12/02/21

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PART 4. Information About Your Family Member (the derivative) (continued)
C. Where Marriage Ended
City or Town

State or Province

Country

D. How Marriage Ended
Annulled

Divorced

Separated

Widowed

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11. Date of Birth (mm/dd/yyyy)

12. Place of Birth
City or Town

State or Province

Country

13. Country of Citizenship or Nationality

14. Passport or Travel Document Number

15. Country That Issued Your Passport or Travel Document

16. Issued Date for Passport or Travel Document
(mm/dd/yyyy)

17. Expiration Date for Passport or Travel Document

18.

Current Immigration Status

(mm/dd/yyyy)

19. Is your family member currently living in the United States?

Yes

No

20. If you answered “Yes” to Item Number 19., give the following information about your family member if he or she is currently in
the United States.
A. Place of Last Entry
City or Town

State

B. Date of Last Entry (mm/dd/yyyy)

C. Form I-94 Arrival-Departure Record Number
►

21. 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.
A. Type of Office (Select one):
Consulate

Pre-flight Inspection Facility

B. City or Town

Form I-914, Supplement A Edition 12/02/21

Port of Entry
C. U.S. State or Foreign Country

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PART 4. Information About Your Family Member (the derivative) (continued)
D. Foreign Address Where You Want Notification Sent
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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22. Give the following information about your family member if he or she has previously traveled to the United States.
A. Place of Entry
City or Town

B. Date of Entry (mm/dd/yyyy)

State

C. Date Authorized Stay Expired
(mm/dd/yyyy)

D. Immigration Status

23. Has your family member ever been in immigration court proceedings?

Yes

No

Yes

No

24. If you answered “Yes” to Item Number 23., what type of proceedings? (Select all that apply)
A.

Removal Date (mm/dd/yyyy)

B.

Exclusion Date (mm/dd/yyyy)

C.

Deportation Date (mm/dd/yyyy)

D.

Recission Date (mm/dd/yyyy)

E.

Next Hearing Date (mm/dd/yyyy)

25. Is your family member requesting an Employment Authorization Document?
If you answered “Yes” to Item Number 25., submit Form I-765, Application for Employment
Authorization Document, with Form I-914, Supplement A, or separately.
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.

Form I-914, Supplement A Edition 12/02/21

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PART 5. 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,
use the space provided in Part 9. Additional Information to explain your answer. 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:
Yes

No

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

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.

Yes

No

A.

Committed a crime or offense for which he or she has not been arrested?

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Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?

If you answered “Yes” to any part of Item Number 1., complete the following table. If you need extra space to complete this
section, use the space provided in Part 9. Additional Information to explain your answer.
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 or Town, State, Country)

2.

Outcome or disposition
(for example, 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

Form I-914, Supplement A Edition 12/02/21

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PART 5. Processing Information (continued)
3.

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.

4.

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

Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)?

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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 the Immigration and Nationality Act section 219?

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

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?

Form I-914, Supplement A Edition 12/02/21

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PART 5. Processing Information (continued)
8.

9.

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 you are filing?

Yes

No

B. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the
family member for whom you are filing?

Yes

No

C. Has the family member for whom you are filing EVER been removed, excluded, or deported from the
United States?

Yes

No

D. Has the family member for whom you are filing EVER been ordered to be removed, excluded, or
deported from the United States?

Yes

No

E. Has the family member for whom you are filing EVER been denied a visa or denied admission to the
United States? (If a visa was denied, use the space provided in Part 9. Additional Information to
explain your answer.)

Yes

No

F.

Yes

No

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Has the family member for whom you are filing EVER been granted voluntary departure by an
immigration officer or an immigration judge and failed to depart within the allotted time?

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 INA section
274C (producing and/or using false documentation to unlawfully satisfy a requirement of the INA)?

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

11. Has the family member for whom you are filing EVER:

Form I-914, Supplement A Edition 12/02/21

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PART 5. Processing Information (continued)
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 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

19. Does the family member for whom you are filing plan to practice polygamy in the United States?

Yes

No

20. Did the family member for whom you are filing enter the United States as a stowaway?

Yes

No

21. 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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PART 6. 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.
B.

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.

The interpreter named in Part 7. 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 8.,
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)

Form I-914, Supplement A Edition 12/02/21

4.

Applicant's Mobile Telephone Number (if any)

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PART 6. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
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).

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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

Applicant's Phone Number (if any)

7.

Date of Signature (mm/dd/yyyy)

Applicant's Safe Phone Number

Signature of Derivative (your family member if physically present in the United States)

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.

PART 7. 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)

2.

Interpreter's Business or Organization Name (if any)

Form I-914, Supplement A Edition 12/02/21

Interpreter's Given Name (First Name)

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PART 7. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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Province

Postal 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 6., 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

Date of Signature (mm/dd/yyyy)

PART 8. 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)

2.

Preparer's Business or Organization Name (if any)

Form I-914, Supplement A Edition 12/02/21

Preparer's Given Name (First Name)

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PART 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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Province

Postal 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.
B.

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

Form I-914, Supplement A Edition 12/02/21

Date of Signature (mm/dd/yyyy)

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Part 9. Additional Information
If you need extra space to provide any additional information within this application, 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 application or attach a separate sheet of paper.
Type or print your name and A-Number 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.
1.

Family Name (Last Name)

2.

A-Number

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name

► A-

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A. Page Number

D.

Given Name (First Name)

A. Page Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

Form I-914, Supplement A Edition 12/02/21

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