Fillable I-914-Form-min Form I-914, Application for T Nonimmigrant Status

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I-914-Form-min Form I-914, Application for T Nonimmigrant Status

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Page 1
Form I-914 02/27/17 Y
Application for T Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
Conditional Approval
For USCIS Use Only
Remarks
Action Block
Returned
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
To Be Completed by
Attorney or Representative, if any
Validity Dates
From:
To:
Stamp # Date
Date
Check all that apply:
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
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. Number
City State/Province Zip/Postal Code
C/O (in care of):
Safe Mailing Address (if other than above) - Street Number and Name Apt. Number
City State/Province Zip/Postal Code
Country of CitizenshipCountry of Birth
Passport Number Place of Issuance
Home Telephone Number
(with area code)
Safe Daytime Phone Number
(with area code)
E-Mail Address (optional)
PART B. General Information About You (Person filing this form as a victim)
Gender
A-Number (if any)
U.S. Social Security Number (if any)
Marital Status:
Date of Issue (mm/dd/yyyy)
Place of Last Entry Date of Last Entry (mm/dd/yyyy)
Male Female
Married
Divorced Widowed
Single/Never Married
Fill in box if G-28 is attached to
represent the applicant.
ATTY State
License #
Date
Date
Date
Date
Date
Date
USCIS
Form I-914
OMB No. 1615-0099
Expires 01/31/2019
Receipt Number (begins with EAC)
I am filing for T-1 nonimmigrant status and have not previously filed for such
status.
I am filing for T-1 nonimmigrant status and have previously filed for such status.
I have received T-1 status and am applying to bring family members to the United
States.
Form I-94 Number (Arrival-Departure Record) Current Immigration Status
Page 2
Form I-914 02/27/17 Y
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. You must 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 require 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, or have been allowed entry into the United
States to participate in investigative or judicial processes associated with an act or perpetrator 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, or am unable to cooperate with such requests due to
physical or psychological trauma. (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
Page 3
Form I-914 02/27/17 Y
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.)
Page 4
Form I-914 02/27/17 Y
2. 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?
3. 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
4. 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
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
Page 5
Form I-914 02/27/17 Y
PART D. Processing Information (continued)
5. 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
6. 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
7. 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
Yes
NoYes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
NoYes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
No
8. Have you EVER been present or nearby when any person was:
a. Intentionally killed, tortured, beaten, or injured?
b. Displaced or moved from his or her residence by force, compulsion, or duress?
c. In any way compelled or forced to engage in any kind of sexual contact or relations?
b. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against you?
9. a. Are removal, exclusion, rescission, or deportation proceedings pending against you?
c. Have you EVER been removed, excluded, or deported from the United States?
d. Have you EVER been ordered to be removed, excluded, or deported from the United States?
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.)
a. Acts involving torture or genocide?
10. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
b. Killing any person?
c. Intentionally and severely injuring any person?
d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?
e. Limiting or denying any person's ability to exercise religious beliefs?
11. Have you EVER:
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?
b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved
detaining persons?
No
Yes No
Yes
Page 6
Form I-914 02/27/17 Y
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)
12. 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?
13. 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?
14. Have you EVER received any type of military, paramilitary, or weapons training?
15. 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)?
16. 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?
17. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?
18. 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?
19. 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?
20. Do you plan to practice polygamy in the United States?
21. Have you entered the United States as a stowaway?
22. a. Do you have a communicable disease of public health significance?
c. Are you now or have you been a drug abuser or drug addict?
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
NoYes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
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
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.
Page 7
Form I-914 02/27/17 Y
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
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 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.
PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part.
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.
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.
Applicant's Statement
The interpreter named in Part G. read to me every question and instruction on this application and my answer to every
a language in which I am fluent, and I understood everything.
question in
B.
,
PART E. Information About Your Family Members (continued)
,
prepared this application for me based only upon information I provided or authorized.
Applicant's Statement Regarding the Preparer2.
At my request, the preparer named in Part H.,
Page 8
Form I-914 02/27/17 Y
PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek.
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:
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.
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.
Applicant's Signature
Date of Signature (mm/dd/yyyy)Applicant's Signature (sign in ink)6.
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.
I authorize the release of any information from my record that 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 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).
Page 9
Form I-914 02/27/17 Y
Interpreter's Contact Information
Interpreter's Certification
Interpreter's Signature
Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any)4.
I am fluent in English and
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.
I certify, under penalty of perjury, that:
, which is the same language specified in Part F., Item B. in
Date of Signature (mm/dd/yyyy)Interpreter's Signature (sign in ink)7.
Interpreter's Mailing Address
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
Postal Code CountryProvince
3.
Interpreter's Email Address (if any)6.
PART G. Interpreter's Contact Information, Certification, and Signature
Interpreter's Business or Organization Name (if any)2.
Interpreter's Family Name (Last Name)1.
Interpreter's Full Name
Interpreter's Given Name (First Name)
Provide the following information about the interpreter.
Page 10
Form I-914 02/27/17 Y
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any) 5.Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
Preparer's Mailing Address
3.
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
Postal Code CountryProvince
Preparer's Statement
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.
7.
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.
A.
B.
extends
PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
2. Preparer's Business or Organization Name (if any)
Preparer's Given Name (First Name)
Preparer's Full Name
Provide the following information about the preparer.
1. Preparer's Family Name (Last Name)
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 (sign in ink) Date of Signature (mm/dd/yyyy)
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I-914-Form-min Form I-914, Application for T Nonimmigrant Status

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Completed 12 July 2020

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