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I-914, Application for T Nonimmigrant Status (ILW.COM)

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I-914, Application for T Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0099; Expires 03/31/11
Form I-914 (Rev. 03/30/09) N
Conditional Approval
Fill in box if G-28 is attached to
represent the applicant.
For USCIS Use Only
Remarks
Action Block
Returned
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
To Be Completed by
Attorney or Representative, if any
Validity Dates
From:
To:
Stamp # Date
ATTY State License #
Date
Check all that apply:
I am filing an application for T-1 nonimmigrant status, and have not previously
filed for such status.
START HERE - Type or print. Use black ink. See Instructions for information
about eligibility and how to complete and file this application.
PART A. Purpose for Filing the Application
I have a T-1 application pending. EAC #:
I am applying to bring family member(s) to the United States.
I have received T-1 status.
Date of Birth (mm/dd/yyyy)
Middle Name (if any)Given Name (First Name)Family Name (Last Name)
Other Names Used (Include maiden name/nickname)
Home Address - Street Number and Name Apt. #
City State/Province Zip/Postal Code
C/O (in care of):
Safe Mailing Address (if other than above) - Street Number and Name Apt. #
City State/Province Zip/Postal Code
Country of CitizenshipCountry of Birth
Passport # Place of Issuance
Home Telephone #
(with area code)
Safe Daytime Phone #
(with area code)
E-Mail Address
(optional)
PART B. General Information About You (Person filing this form as a victim)
GenderA # (if any) U.S. Social Security # (if any)
Male Female
Marital Status:
Single/Never MarriedMarried
WidowedDivorced
Date of Issue (mm/dd/yyyy)
Place of Last Entry
Current Immigration StatusI-94 # (Arrival/Departure Document)
Date of Last Entry (mm/dd/yyyy)
Answers to the following questions about your claim require explanation and supporting documentation. You should attach
documents in support of your claim that you are a victim of a severe form of trafficking in persons and the specific facts on which you
are relying to support your claim. It is strongly encouraged that you attach a personal narrative statement describing the trafficking. If
you are only applying for T derivative status for a family member subsequent to your (the principal applicant) initial filing, evidence
supporting the original application is not required to be resubmitted with the new Form I-914.
Attach additional sheets of paper as needed. Write your name and Alien Registration Number (A-Number), if any, at the top of each
sheet and indicate the number of the item that you are answering. Include the Part and letter or number relating to the additional
information you provided (example: Part C, 3).
PART C. Additional Information
Yes No
Yes No
1. I am or have been a victim of a severe form of trafficking in persons. (Attach evidence to support your claim.)
2. I am submitting a law enforcement agency (LEA) declaration on Form I-914, Supplement B, Declaration of
Law Enforcement Officer for Victim of Trafficking in Persons. (If "No," explain why you are not submitting the
LEA Certification.)
Yes No
3. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana
Islands, or at a port of entry, on account of trafficking. (If "Yes," explain in detail and attach evidence and
documents supporting this claim.)
Yes No
4. I fear that I will suffer extreme hardship involving unusual and severe harm upon removal. (If "Yes," explain in
detail and attach evidence and documents supporting this claim.)
Yes No
5. I have reported the crime of which I am claiming to be a victim. (If "Yes," indicate to which law enforcement
agency and office you have made the report, the address and phone number of that office, and the case number
assigned, if any. If "No," explain the circumstances.)
Law Enforcement Agency and Office Address Phone Number Case Number
Circumstances:
Yes No
7. I have complied with requests from Federal, State, or local law enforcement authorities for assistance in the
investigation or prosecution of acts of trafficking. (If "No," explain the circumstances.)
6. I am under the age of 18 years. (If "Yes," proceed to Question 8.)
Yes No
8. This is the first time I have entered the United States. (If "No," list each date, place of entry, and under which
status you entered the United States for the past five years, and explain the circumstances of your most recent
arrival.)
Yes No
Date of Entry Place of Entry Status
Form I-914 (Rev. 03/30/09) N Page 2
PART C. Additional Information (Continued)
Yes No
9. My most recent entry was on account of the trafficking that forms the basis for my claim. (Explain the
circumstances of your most recent arrival.)
Yes No
10. I want an Employment Authorization Document.
Yes No
11. I am now applying for one or more eligible family members. (If "Yes," complete and include a Form I-914,
Supplement A, Application for Immediate Family Member of T-1 Recipient, for each family member for whom
you are now applying. You may also apply to bring eligible family members to the United States at a later
date.)
PART D. Processing Information
1. Have you EVER:
Yes No
a. Committed a crime or offense for which you have not been arrested?
Yes No
b. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military
officers) for any reason?
Yes No
c. Been charged with committing any crime or offense?
Yes No
d. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)?
Yes No
e. Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred
prosecution, withheld adjudication, deferred adjudication)?
Yes No
f. Received a suspended sentence, been placed on probation, or been paroled?
Yes No
g. Been in jail or prison?
Yes No
h. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action?
Yes No
i. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?
Answer the following questions about yourself. For purposes of this application, if applicable, you must answer “Yes” to the
following questions, 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. (If your answer is "Yes" to any one of these questions, explain on a separate sheet
of paper. Additionally, explain if any of the acts or circumstances below are related to you having been a victim of a severe form of
trafficking. Answering "Yes" does not necessarily mean that you will be denied T nonimmigrant status or are not entitled to adjust
your status or register for permanent residence.)
If you answered “Yes” to any of the above questions, complete the following table. If you need more space, use a separate sheet
of paper to give the same information.
Why were you arrested, cited,
detained, or charged?
Date of arrest,
citation, detention,
charge
(mm/dd/yyyy)
Where were you arrested,
cited, detained, or
charged?
(City, State, Country)
Outcome or disposition
(e.g., no charges filed,
charges dismissed, jail,
probation, etc.)
Form I-914 (Rev. 03/30/09) N Page 3
Yes No
2. Have you EVER received public assistance in the United States from any source, including the U.S.
Government or any State, county, city or other municipality (other than emergency medical treatment), or are
you likely to receive public assistance in the future?
3. Have you:
PART D. Processing Information (Continued)
a. Engaged in prostitution or procurement of prostitution or do you intend to engage in prostitution or
procurement of prostitution?
Yes No
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?
4. Have you EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered
information for, or solicited funds for any of the following:
a. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)?
Yes No
b. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to
compel a third person (including a governmental organization) to do or abstain from doing any act as an
explicit or implicit condition for the release of the individual seized or detained?
Yes No
c. Assassination?
Yes No
d. The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or
to cause substantial damage to property?
Yes No
e. The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon
or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or
to cause substantial damage to property?
Yes No
5. 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 an organization that is:
a. Designated as a terrorist organization under section 219 of the Immigration and Nationality Act?
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:
3. Assassination?
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
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
Form I-914 (Rev. 03/30/09) N Page 4
Yes
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?
No
PART D. Processing Information (Continued)
6. Do you intend to engage in the United States in:
a. Espionage?
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
7. Have you ever been or do you continue to be a member of the Communist or other totalitarian party, except
when membership was involuntary?
Yes No
8. Have you, 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
9. Have you 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
b. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against you?
10. a. Are removal, exclusion, rescission, or deportation proceedings pending against you?
Yes No
c. Have you EVER been removed, excluded, or deported from the United States?
Yes No
Yes No
Yes
d. Have you EVER been ordered to be removed, excluded, or deported from the United States?
No
f. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge and
failed to depart within the allotted time?
e. Have you EVER been denied a visa or denied admission to the United States? (If a visa was denied,
explain why on a separate sheet of paper.)
Yes No
Yes No
a. Acts involving torture or genocide?
11. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
Yes No
b. Killing any person?
Yes No
Yes
c. Intentionally and severely injuring any person?
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
Form I-914 (Rev. 03/30/09) N Page 5
b. Do you have or have you 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?
PART D. Processing Information (Continued)
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?
12. Have you EVER:
Yes No
b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved
detaining persons?
Yes No
13. Have you EVER 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. Have you EVER 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
15. Have you EVER received any type of military, paramilitary, or weapons training?
Yes No
16. Are you under a final order or civil penalty for violating section 274C (producing and/or using false
documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)?
Yes No
17. 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
18. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?
Yes No
19. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence
requirement and not yet complied with that requirement or obtained a waiver of such?
Yes No
20. Have you 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
21. Do you plan to practice polygamy in the United States?
Yes No
22. Have you entered the United States as a stowaway?
Yes No
23. a. Do you have a communicable disease of public health significance?
Yes No
Yes No
c. Are you now or have you been a drug abuser or drug addict?
Yes No
Form I-914 (Rev. 03/30/09) N Page 6
I authorize the release of any information from my record that U.S. Citizenship and Immigration Services (USCIS) needs to determine
eligibility for the benefit I am seeking, 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).
PART E. Information About Your Family Members
Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy)
Country of Birth Current Location
1.
Spouse
Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy)
Country of Birth Relationship Current Location
2.
Children
Provide the following information about your spouse and all of your sons and daughters. If you need more space, attach an additional
sheet of paper.
a.
Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy)
Country of Birth Relationship Current Location
c.
Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (mm/dd/yyyy)
Country of Birth Relationship Current Location
b.
Complete Form I-914, Supplement A, Application for Immediate Family Member of T-1 Recipient, for each family member listed
above for whom you are now applying to have join you in the United States, and attach it to this application.
I have read, or had read to me, this form, the information provided on it and the evidence provided with it, and I certify, under penalty
of perjury under the laws of the United States of America, that all of the information in this entire application package, including the
documentary evidence submitted with it, is true and correct.
After reading the information regarding penalties in the instructions, complete and sign below. If someone helped you prepare this
application, he or she must complete Part G.
PART F. Attestation, Release, and Signature
Form I-914 (Rev. 03/30/09) N Page 7
Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the
language, a language in which I am fluent, by the person named in Interpreter's Statement and
Signature. I understand each and every question and instruction on this form, as well as my answer to each question.
I can read and understand English, and I have read and understand each and every question and instruction on this form, as well
as my answer to each question.
Applicant's Statement (Check one):
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this application is
all true and correct. I certify also that I have not withheld any information that would affect the outcome of this application.
PART G. Preparer and/or Interpreter Certification (To be completed and signed if form is prepared by a person
other than the applicant)
I declare that I prepared this application at the request of the above person, and it is based on all information of which I have
knowledge. I have not knowingly withheld any material information that would affect the outcome of this application.
Date (mm/dd/yyyy)
Preparer's Signature
Attorney or Representative:
In the event of a Request for Evidence, may USCIS contact you by fax or e-mail?
Yes No
Date (mm/dd/yyyy)
Signature of Applicant (the Person in Part A)
Preparer's Statement and Signature (if applicable)
Preparer's Address
Daytime Phone Number (with area code) Fax Number (if any)
Preparer's Printed Name Preparer's Firm Name (if applicable)
E-Mail Address (if any)
PART F. Attestation, Release, and Signature (Continued)
I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as
well as the answer to each question.
Date (mm/dd/yyyy)
Interpreter's Signature
Printed Name Telephone Number (with area code)
Language Used (language in which applicant is fluent):
I certify that I am fluent in English and the below-mentioned language.
Interpreter's Statement and Signature (if applicable)
Form I-914 (Rev. 03/30/09) N Page 8
WARNING: Applicants who are in the United States illegally are subject to removal if their claims are not
granted. Any information provided in completing this application may be used as a basis for the institution of, or
as evidence in, removal proceedings even if the application is later withdrawn.
a. I am or have been a victim of a severe form of trafficking;
b. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana Islands, or at a
port of entry, on account of trafficking;
c. I am cooperating with Federal, State, or local law enforcement authorities in the investigation or prosecution of the traffickers
(unless under age 18); and
d. I would suffer extreme hardship involving unusual and severe harm upon removal from the United States.
PART H. Checklist
I completely filled out and signed the form.
I have attached evidence that:
I have included three photographs of myself.
If I am applying for one or more family members:
I have completed Form I-914, Supplement A for each member for whom I am now applying and, if he or she is in the
United States, each family member has signed that Form I-914, Supplement A.
a. My relationship to the family member for whom I am applying;
c. My child's age, if I am applying for my child; and
d. My sibling's age, if I am applying for my unmarried sibling; and
b. My age, if I am applying for my parent or unmarried sibling under the age of 18;
I have submitted the required evidence, including evidence of:
I have included three photographs of each family member for whom I am now applying.
I have included Form I-765, Application for Employment Authorization, if I am requesting employment authorization for my
family member, along with fee or request for fee waiver.
Form I-914 (Rev. 03/30/09) N Page 9
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I-914, Application for T Nonimmigrant Status (ILW.COM)

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Completed 9 January 2021

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