TABLE OF CHANGES – FORM
Form I-941, Application for Entrepreneur Parole
OMB Number: 1615-0136
08/19/2024
Reason for Revision: FY25 IEP Final Rule Project Phase: 30-Day
Legend for Proposed Text:
Edition Date 10/01/2024 Expires 03/31/2027 |
Current Page Number and Section |
Current Text |
Proposed Text |
Page 1, For USCIS Use Only |
[Page 1]
For USCIS Use Only Receipt Action Block 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.
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Pages 1-3, Part 1. Information About Entrepreneur (Applicant) |
[Page 1]
Part 1. Information About 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) Given Name (First Name) Middle Name (if applicable)
4. 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) [x2] Given Name (First Name) [x2] Middle Name (if applicable) [x2]
Other Information
5. Alien Registration Number (A-Number) (if any)
6. USCIS Online Account Number (if any)
7. U.S. Social Security Number (if any)
8. Date of Birth (mm/dd/yyyy)
[Page 2]
9. Gender Male / Female / Another Gender Identity
10. Country of Birth
11. Country of Citizenship or Nationality
12. Date of Last Arrival in the United States (mm/dd/yyyy)
13. Immigration Status at Your Last Arrival (for example, B-2 Visitor, F-1 Student, or no Status)
14. 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 (excluding minor traffic violations)? Yes No
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 ZIP Code
[Page 3]
20. Entrepreneur’s Current Physical Address
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country
Entrepreneur's Education
21. Name of Institution of Higher Learning
22. Type of Degree/Major Field of Study
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Page 3, Part 2. Biographic Information |
[Page 3]
Part 2. Biographic Information
1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino
2. Race (Select all applicable boxes) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
3. Height Feet/Inches
4. Weight Pounds
5. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other
6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
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Pages 3-4, Part 3. Information About Family Members Requesting Parole or Re-Parole with Entrepreneur |
[Page 3]
Part 3. Information About Family Members Requesting Parole or Re-Parole with Entrepreneur
1. Entrepreneur’s Spouse’s Information
Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)
2. Alien Registration Number A-Number (if any)
3. USCIS Online Account Number (if any)
4. Date of Birth (mm/dd/yyyy)
5. Country of Birth
6. Country of Citizenship or Nationality
[Page 4]
7. Entrepreneur’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.
Family Name (Last Name) [x2] Given Name (First Name) [x2] Middle Name (if applicable) [x2]
Entrepreneur’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)
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)
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
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Page 4, Part 4. Information About Additional Entrepreneurs Requesting or Have Been Granted Parole or Re-Parole with the Same Start-up Entity |
[Page 4]
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)
Receipt Number
2. Entrepreneur 2
Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)
Receipt Number
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Pages 4-8, Part 5. Basis of Eligibility – Qualifying Start-Up Entity and Owners |
[Page 4]
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
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 $264,147 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.
[Page 6]
12. Did your start-up entity receive a qualified government award or grant of at least $105,659 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.
13.a. Amount of Qualified Government Award or Grant
13.b. Date Qualified Grant or Award Received (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? 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 $528,293 in qualifying investments, qualified government awards or grants, or a combination of such funding during the initial parole period? Yes No N/A
Provide the amounts of qualifying investments, qualified government awards or grants.
[Page 7]
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
Provide the number of qualified jobs.
23. Did your start-up reach at least $528,293 in annual revenue in the United States during the initial parole period? Yes No N/A
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? Yes No N/A
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? Yes No N/A
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
29.b. Number of Members of Household
[Page 8]
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.
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 Calendar Year
32.b. Number of Members of 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) Middle Name (if applicable)
Legal Entity Name (if any)
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)
U.S. Social Security Number (if any)
USCIS Online Account 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.
[Page 9]
Address and Contact Information
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code 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) Middle Name (if applicable)
Legal Entity Name (if any)
Trade Name “DBA” (Doing Business As)
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 10. Additional Information.
Family Name (Last Name) Given Name (First Name) Middle Name
Other Information
A-Number (if any)
U.S. Social Security Number (if any)
USCIS Online Account 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.
[Page 10]
Address and Contact Information
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country
Daytime Telephone Number
Fax Number
Email Address (if any)
Website Address (if any)
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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
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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
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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? Yes No N/A
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23. Did your start-up reach at least $622,142 in annual revenue in the United States during the initial parole period? Yes No N/A
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Pages 8-12, Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award |
[Page 8]
Part 6. Information on Qualified Investors or Government Entities Providing a Grant/Award
1. Name of Investor (if an individual)
Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)
2. Date of Birth (mm/dd/yyyy)
3. A-Number (if any)
4. U.S. Social Security Number (if any)
5. Country of Birth
6. Mailing Address and Contact Information
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country
7. Daytime Telephone Number
8. Email Address (if any)
9. Website Address (if any)
Information on Investment
10.a. Aggregate Amount of Investment
10.b. Types of Investment (for example, equity or convertible debt)
[Page 11]
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
List investments in other start-ups by this investor during the preceding five years totaling no less than $633,952. If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
13. Name of Company
14. DUNS Number (if any)
15. Year of Investment
16. Amount of Investment
17. Type of investment
18. Company Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal 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 $528,293 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 ZIP Code Province Postal Code Country
[Page 12]
19.b. Company 2
Name of Company
DUNS Number (if any)
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal 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
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country
22. Daytime Telephone Number
23. Email Address (if any)
24. Website Address (if any)
Information on Investment
25.a. Aggregate Amount of Investment
25.b. Types of Investment (for example, equity or convertible debt)
[Page 11]
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? Yes No
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
List investments in other start-ups by this investor during the preceding five years totaling no less than $633,952. If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
28. Name of Company
29. DUNS Number (if any)
30. Year of Investment
31. Amount of Investment
32. Type of Investment
33. Address Information
Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal 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 $528,293 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 ZIP Code Province Postal Code Country
[Page 14]
34.b. Company 2
Name of Company
DUNS Number (if any)
Street Number and Name
Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal 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 ZIP Code Province Postal Code Country
37. Daytime Telephone Number
38. Email Address (if any)
39. Website Address (if any)
Information on Grant/Award
40.a. Aggregate of Amount of Grant/Award
40.b. Type of Grant/Award
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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.
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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.
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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.
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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.
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Pages 12-13, Part 7. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature |
[Page 12]
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
2. Applicant’s Mobile Telephone Number (if any)
3. Applicant’s Email Address (if any)
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)
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Page 13, Part 8. Interpreter’s Contact Information, Certification, and Signature |
[Page 13]
Part 8. Interpreter’s Contact Information, Certification, and Signature
Interpreter’s Full Name
1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name)
2. Interpreter’s Business or Organization Name
Interpreter’s Contact Information
3. Interpreter’s Daytime Telephone Number
4. Interpreter’s Mobile Telephone Number (if any)
5. Interpreter’s Email Address (if any)
Interpreter’s Certification and Signature
I certify, under penalty of perjury, that I am fluent in English and [Fillable Field], 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)
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Page 14, Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant |
[Page 14]
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) Preparer’s Given Name (First Name)
2. Preparer’s Business or Organization Name
Preparer’s Contact Information
3. Preparer’s Daytime Telephone Number
4. Preparer’s Mobile Telephone Number (if any)
5. Preparer’s Email Address (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 Date of Signature (mm/dd/yyyy)
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Page 17, Part 10. Additional Information |
[Page 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 startup 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 2. Start-Up Entity Identification Number
3. Page Number Part Number Item Number [Fillable Field]
4. Page Number Part Number Item Number [Fillable Field]
5. Page Number Part Number Item Number [Fillable Field]
6. Page Number Part Number Item Number [Fillable Field]
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Carter, Pea Meng |
| File Modified | 0000-00-00 |
| File Created | 2024-10-28 |