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pdfUSCIS
Form I-941
Application for Entrepreneur Parole
Department of Homeland Security
U.S. Citizenship and Immigration Services
Receipt
For
USCIS
Use
Only
OMB No. 1615-0136
Expires 03/31/2027
Action Block
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PRODUCTION
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Remarks
To be completed by an
Attorney or Accredited
Representative (if any).
Select this box if
Form G-28 or
G-28I is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
► START HERE - Type or print in black ink.
Part 1. Information About the Entrepreneur (Applicant)
1.
I am requesting:
Initial Parole OR
Re-Parole OR
Amended Application
If you are requesting a re-parole or filing an amended application, provide the Receipt Number of your current Form I-941 approval
in Item Number 2. below.
2.
Receipt Number
►
3.
Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)
4.
Given Name (First Name)
Middle Name (if applicable)
Other Names Used (if any)
Provide all other names you have used, including aliases, maiden name, and nicknames. If you need extra space to complete this
section, use the space provided in Part 10. Additional Information.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Other Information
5.
Alien Registration Number (A-Number) (if any)
► A-
7.
U.S. Social Security Number (if any)
6.
USCIS Online Account Number (if any)
►
8.
Date of Birth (mm/dd/yyyy)
►
Form I-941 Edition 05/06/24
Page 1 of 17
Part 1. Information About the Entrepreneur (Applicant) (continued)
9.
Gender
Male
Female
Another Gender Identity
10.
Country of Birth
12.
Date of Last Arrival in the United States (if any)
11.
Country of Citizenship or Nationality
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(mm/dd/yyyy)
14.
13.
Immigration Status at Your Last Arrival (for example, B-2
Visitor, F-1 Student or no Status)
Your Current Immigration Status or Category (for example,
B-2 visitor, F-1 student, parolee, deferred action, or no
status or category)
15.
Have you EVER been arrested, cited, charged, indicted, convicted, fined, or imprisoned for violating any law or ordinance
Yes
No
(excluding minor traffic violations)?
16.
Have you EVER committed any crime for which you were not arrested?
Yes
No
If you answered "Yes" to Item Number 15., you must provide certified court dispositions, arrest reports, statements of charges,
indictment information, or any other charging documents that were issued. If you answered "Yes" to Item Number 16., provide
the date and location (town or city/state or province/country) of the events and provide an explanation in the space provided in
Part 10. Additional Information.
17.
Have you, or any person included in this application, ever been in exclusion, deportation, removal, or rescission proceedings, or
are you now in such proceedings?
Yes
No
If you answered "Yes" to Item Number 17., provide the following information below:
Name of Person(s) in Proceedings:
18.
Where do you want USCIS to send all travel documents for you, and your spouse and dependent children (if applicable)?
To the U.S. address in Part 1., Item Number 19.
To a U.S. Embassy or U.S. Consulate at:
Name of U.S. Embassy or U.S. Consulate
To a Department of Homeland Security (DHS) office overseas at:
Name of DHS Office
19.
Entrepreneur's Current U.S. Mailing Address (if applicable)
In Care Of Name (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Form I-941 Edition 05/06/24
ZIP Code
Page 2 of 17
Part 1. Information About the Entrepreneur (Applicant) (continued)
20.
Entrepreneur's Current Physical Address
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
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Province
Postal Code
Country
Entrepreneur's Education
21.
Name of Institution of Higher Learning
22.
Type of Degree/Major Field of Study
Part 2. Biographic Information
1.
Ethnicity (Select only one box)
Hispanic or Latino
2.
Not Hispanic or Latino
Race (Select all applicable boxes)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
3.
Height
5.
Eye Color (Select only one box)
Feet
Black
Gray
Maroon
4.
Inches
Blue
Green
Pink
White
Weight
Pounds
Hair Color (Select only one box)
6.
Brown
Hazel
Unknown/Other
Bald (No hair)
Brown
Sandy
Blond
Red
Black
Gray
White
Unknown/Other
Part 3. Information About Family Members Requesting Parole or Re-Parole with Entrepreneur
1.
Entrepreneur's Spouse's Information
Family Name (Last Name)
2.
Given Name (First Name)
Alien Registration Number A-Number (if any)
3.
USCIS Online Account Number (if any)
► A-
►
5.
4.
Date of Birth (mm/dd/yyyy)
6.
Country of Citizenship or Nationality
Form I-941 Edition 05/06/24
Middle Name (if applicable)
Country of Birth
Page 3 of 17
Part 3. Information About Family Members Requesting Parole or Re-Parole with Entrepreneur
(continued)
7.
Entreprenuer's Spouse's Other Names Used
Provide any other names your spouse has used since birth, including aliases, maiden name, and nicknames. If you need extra
space to complete this section, use the space provided in Part 10. Additional Information.
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Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Entreprenuer's Dependent Children
Provide the following information about each child. If you need extra space to complete this section, use the space provided in
Part 10. Additional Information.
8.a. Child 1
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
A-Number (if any)
USCIS Online Account Number (if any)
► A-
►
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
8.b. Child 2
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
A-Number (if any)
USCIS Online Account Number (if any)
► A-
►
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Part 4. Information About Additional Entrepreneurs Requesting or Have Been Granted Parole or
Re-Parole with the Same Start-up Entity
1.
Entrepreneur 1
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Given Name (First Name)
Middle Name (if applicable)
Receipt Number ►
2.
Entrepreneur 2
Family Name (Last Name)
Receipt Number ►
Form I-941 Edition 05/06/24
Page 4 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners
Information About the Qualifying Start-Up Entity
1.
Start-Up Entity Legal Name
2.
Start-Up Entity Address
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Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
3.
Federal Employer Identification Number
4.
DUNS Number (if any)
5.
Trade Name "DBA" (Doing Business As)
6.
Date Start-Up Entity Established in United States
(mm/dd/yyyy)
7.
Number of Full-Time Employees
in United States
8.
Your Ownership Stake/Percentage
of Start-Up Entity
%
Applying for Initial Parole
9.
Explanatory Statement. Provide a detailed statement explaining how you meet the criteria for entrepreneur parole. Your
statement should include an explanation of your role in the operations of that entity, as well as how your involvement with the
start-up entity will advance the start-up entity's growth and business success such as to result in a significant public benefit. You
may provide this statement in the space provided in Part 10. Additional Information or attach a separate sheet of paper; type
or print your name and startup entity identification 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.
10.
Did your start-up entity receive a qualified investment of at least $311,071 within 18 months immediately
preceding the filing of this application?
Yes
No
If you answered "Yes" to Item Number 10., provide the amount of qualified investment and date the qualified investment was
received in Item Numbers 11.a. - 11.b.
11.a. Amount of Qualified Investment
$
11.b. Date Qualified Investment Received
(mm/dd/yyyy)
If you need more space to complete this section, use the space provided in Part 10. Additional Information.
Form I-941 Edition 05/06/24
Page 5 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners (continued)
12.
Did your start-up entity receive a qualified government award or grant of at least $124,429 within 18 months
immediately preceding the filing of this application?
Yes
No
If you answered "Yes" to Item Number 12., provide the amount of qualified government award or grant and date the qualified
government award or grant was received in Item Numbers 13.a. - 13.b.
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13.a. Amount of Qualified Government Award
13.b. Date Qualified Grant or Award Received
or Grant $
(mm/dd/yyyy)
If you need more space to complete this section, use the space provided in Part 10. Additional Information.
Alternative Criteria
14.
Does your start-up entity partially meet one or both of the above threshold criteria?
Yes
No
N/A
If you answered "Yes" to Item Number 14., provide the amounts of qualified investment and/or qualified government award or
grant that was received in Item Numbers 15.a. - 15.b.
15.a. Amount of Qualified Investment
$
15.b. Amount of Qualified Government Award
or Grant $
Applying for Re-Parole
16.
Is this the same start-up entity for which you were granted an initial parole?
Yes
No
If you answered "No" to Item Number 16., explain the current status of the start-up entity for which you were granted initial
parole in Item Number 17. If you need more space to complete this section, use the space provided in Part 10. Additional
Information.
17.
Explanation
Re-Parole Criteria
Provide evidence that you continue to meet the definition of entrepreneur and that your business continues to meet the definition of
start-up entity.
18.
Do you own at least 5% of the shares, or similar type of equity interest, in the start-up entity?
Yes
No
19.
Do you continue to perform an active and central role in the start-up entity?
Yes
No
20.
Is the start-up entity continuing to lawfully operate in the United States?
Yes
No
21.
Did your start-up entity receive at least $622,142 in qualifying investments, qualified government
awards or grants, or a combination of such funding during the initial parole period?
No
N/A
Yes
Provide the amounts of qualifying investments, qualified government awards or grants. $
Form I-941 Edition 05/06/24
Page 6 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners (continued)
22.
Did your start-up entity create at least 5 qualified jobs with the start-up entity during the initial
parole period?
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Provide the number of qualified jobs.
23.
Did your start-up reach at least $622,142 in annual revenue in the United States during the initial
parole period?
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Provide the amount of annual revenue generated. $
24.
Did the annual revenue generated by your start-up entity in the United States average 20 percent
growth during the initial parole period?
Provide the percentage of annual revenue growth.
%
Alternative Criteria
25.
Does your start-up entity partially meet one or more of the above threshold criteria?
If you answered "Yes" to Item Number 25., provide the applicable information requested in Item Numbers 26.a. - 26.c.
26.a. Total Amount of Revenue Generated During Initial
Period of Parole
$
26.b. Total Amount of Additional Qualified Investment,
Government Grants or Awards During Initial
Period of Parole
$
26.c. Total Number of Qualified Jobs Created During
Initial Period of Parole
27.
Provide a detailed statement explaining how you continue to meet the criteria for entrepreneur parole. Your statement should
include an explanation of your continued or new role in the operations of that entity, as well as how your involvement with the
start-up entity will advance the start-up entity's growth and business success such as to result in a significant public benefit. You
may provide this statement in the space provided in Part 10. Additional Information or attach a separate sheet of paper; type
or print your name and startup entity identification 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.
28.
Are you maintaining a household income that is greater than 400 percent of the Federal Poverty Guidelines?
Yes
No
If you answered "Yes" to Item Number 28., provide the information requested in Item Numbers 29.a. - 29.b.
29.a. Amount of Household Income in Last Full
Calendar Year $
Form I-941 Edition 05/06/24
29.b. Number of Members of
Household
Page 7 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners (continued)
Filing an Amended Application to Report a Material Change
In the space below, provide a detailed explanation of any material changes to the facts on which your parole was based. If you need more
space to complete this section, use the space provided in Part 10. Additional Information.
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30.
Explanation
31.
Are you maintaining a household income that is greater than 400 percent of the Federal Poverty Guidelines?
Yes
No
If you answered "Yes" to Item Number 31., provide the information requested in Item Numbers 32.a. - 32.b.
32.a. Amount of Household Income in Last Full
32.b. Number of Members of
Calendar Year $
Household
Information About the Owners of the Start-Up Entity
If there are multiple owners of the start-up entity, you must list all other individuals or entities that own a share of the start-up entity
and identify their ownership percentage.
33.a. Owner 1
Family Name (Last Name)
Given Name (First Name)
Legal Entity Name (if any)
Middle Name (if applicable)
Trade Name "DBA" (Doing Business As)
Other Names Used
Provide any other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 10. Additional Information.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Other Information
A-Number (if any)
► AUSCIS Online Account Number (if any)
U.S. Social Security Number (if any)
►
Date of Birth (mm/dd/yyyy)
►
Country of Birth
Country of Citizenship or Nationality
Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.
Position Held (if any) in the Entity Listed in Part 5., Item
Number 1.
Form I-941 Edition 05/06/24
Page 8 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners (continued)
Address and Contact Information
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
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Province
Postal Code
Country
Daytime Telephone Number
Fax Number
Email Address (if any)
Website Address (if any)
33.b. Owner 2
Family Name (Last Name)
Given Name (First Name)
Legal Entity Name (if any)
Middle Name (if applicable)
Trade Name "DBA" (Doing Business As)
Other Names Used
Provide any other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 10. Additional Information.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other Information
A-Number (if any)
► AUSCIS Online Account Number (if any)
U.S. Social Security Number (if any)
►
Date of Birth (mm/dd/yyyy)
►
Country of Birth
Country of Citizenship or Nationality
Percentage of Ownership in the Start-Up Entity Listed in Part Position Held (if any) in the Entity Listed in Part 5., Item
5., Item Number 1.
Number 1.
Form I-941 Edition 05/06/24
Page 9 of 17
Part 5. Basis of Eligibility - Qualifying Start-Up Entity and Owners (continued)
Address and Contact Information
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
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Province
Postal Code
Country
Daytime Telephone Number
Fax Number
Email Address (if any)
Website Address (if any)
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award
1.
Name of Investor (if an individual)
Family Name (Last Name)
2.
Date of Birth (mm/dd/yyyy)
Given Name (First Name)
3.
Middle Name (if applicable)
A-Number (if any)
► A-
4.
U.S. Social Security Number (if any)
►
6.
5.
Country of Birth
Mailing Address and Contact Information
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
7.
Daytime Telephone Number
9.
Website Address (if any)
Postal Code
ZIP Code
Country
8.
Email Address (if any)
Information on Investment
10.a. Aggregate Amount of Investment
10.b. Types of Investment (for example, equity or convertible debt)
$
Form I-941 Edition 05/06/24
Page 10 of 17
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award (continued)
Qualified Investor Verification
11.
Is the investor a U.S. citizen or lawful permanent resident of the United States?
Yes
No
12.
Has the investor been permanently or temporarily enjoined from participating in the offer or sale of a security
or in the provision of services as an investment adviser, broker, dealer, municipal securities dealer,
government securities broker, government securities dealer, bank, transfer agent or credit rating agency;
barred from association with any entity involved in the offer or sale of securities or provision of such services;
or otherwise found to have participated in the offer or sale of securities or provision of such services in
violation of law?
Yes
No
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List investments in other start-ups by this investor during the preceding five years totaling no less than $746,571. If you need
extra space to complete this section, use the space provided in Part 10. Additional Information.
13.
Name of Company
15.
Year of Investment
17.
Type of Investment
18.
Company Address
14.
16.
DUNS Number (if any)
Amount of Investment $
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
ZIP Code
Country
Identify at least 2 of the start-ups listed above that each created, subsequent to such investment, at least 5 qualified jobs or
generated at least $622,142 in revenue with average annualized revenue growth of at least 20 percent.
19.a. Company 1
Name of Company
DUNS Number (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Form I-941 Edition 05/06/24
Postal Code
ZIP Code
Country
Page 11 of 17
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award (continued)
19.b. Company 2
Name of Company
DUNS Number (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
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Province
Postal Code
ZIP Code
Country
Name of Investor (if an organization such as a Venture Capital Firm, Accelerator or Incubator)
20.a. Legal Entity Name
20.b. Trade Name "DBA" (Doing Business As)
20.c. DUNS Number (if any)
21.
Address and Contact Information
Name of Company
DUNS Number (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
22.
Daytime Telephone Number
24.
Website Address (if any)
Postal Code
ZIP Code
Country
23.
Email Address (if any)
Information on Investment
25.a. Aggregate Amount of Investment
25.b. Types of Investment (for example, equity or convertible debt)
$
Form I-941 Edition 05/06/24
Page 12 of 17
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award (continued)
Qualified Investor Verification
26.
Is the investor majority owned and controlled, directly and indirectly, by U.S. citizens or lawful permanent
residents of the United States?
27.
Has the investor been permanently or temporarily enjoined from participating in the offer or sale of a
security or in the provision of services as an investment adviser, broker, dealer, municipal securities dealer,
government securities broker, government securities dealer, bank, transfer agent or credit rating agency;
barred from association with any entity involved in the offer or sale of securities or provision of such
services; or otherwise found to have participated in the offer or sale of securities or provision of such
services in violation of law?
Yes
No
Yes
No
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List investments in other start-ups by this investor during the preceding five years totaling no less than $746,571. If you need
extra space to complete this section, use the space provided in Part 10. Additional Information.
28.
Name of Company
30.
Year of Investment
32.
Type of Investment
33.
Address Information
29.
31.
DUNS Number (if any)
Amount of Investment $
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
ZIP Code
Country
Identify at least 2 of the start-ups listed above that each created, subsequent to such investment, at least 5 qualified jobs or
generated at least $622,142 in revenue with average annualized revenue growth of at least 20 percent.
34.a. Company 1
Name of Company
DUNS Number (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Form I-941 Edition 05/06/24
Postal Code
ZIP Code
Country
Page 13 of 17
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award (continued)
34.b. Company 2
Name of Company
DUNS Number (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
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Province
Postal Code
ZIP Code
Country
Name of Government Entity Providing Grant/Award
35.
Name of Approving Official
36.
Address and Contact Information
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
37.
Daytime Telephone Number
39.
Website Address (if any)
Postal Code
ZIP Code
Country
38.
Email Address (if any)
Information on Grant/Award
40.a. Aggregate Amount of Grant/Award
40.b. Type of Grant/Award
$
Form I-941 Edition 05/06/24
Page 14 of 17
Part 7. Applicant's Contact Information, Certification, and Signature
Applicant's Contact Information
Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.
Applicant's Daytime Telephone Number
3.
Applicant's Email Address (if any)
2.
Applicant's Mobile Telephone Number (if any)
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Applicant's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 8.,
understood, all of the responses and information contained in, and submitted with, my application, and that all of the responses and the
information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
4.
Applicant's Signature
Date of Signature (mm/dd/yyyy)
Part 8. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
2.
Interpreter's Business or Organization Name
Interpreter's Given Name (First Name)
Interpreter's Contact Information
3.
Interpreter's Daytime Telephone Number
5.
Interpreter's Email Address (if any)
4.
Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification and Signature
I certify, under penalty of perjury, that I am fluent in English and
, and I have interpreted every
question on the application and Instructions and interpreted the applicant's answers to the questions in that language, and the applicant
informed me that they understood every instruction, question, and answer on the application.
6.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Form I-941 Edition 05/06/24
Page 15 of 17
Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Preparer's Full Name
1.
Preparer's Family Name (Last Name)
2.
Preparer's Business or Organization Name
Preparer's Given Name (First Name)
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Preparer's Contact Information
3.
Preparer's Daytime Telephone Number
5.
Preparer's Email Address (if any)
4.
Preparer's Mobile Telephone Number (if any)
Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of responses and information contained in and submitted with the application, are complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.
Preparer's Signature
Form I-941 Edition 05/06/24
Date of Signature (mm/dd/yyyy)
Page 16 of 17
Part 10. 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 the start-up entity's name 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.
Name of Start-Up Entity
3.
Page Number
Part Number Item Number
4.
Page Number
Part Number Item Number
5.
Page Number
Part Number Item Number
6.
Page Number
Part Number Item Number
7.
Page Number
Part Number Item Number
2.
Start-Up Entity Identification Number
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Form I-941 Edition 05/06/24
Page 17 of 17
| File Type | application/pdf |
| File Title | Form I-941, Application for Entrepreneur Parole |
| Author | USCIS |
| File Modified | 2024-08-19 |
| File Created | 2024-08-19 |