Application for T Nonimmigrant Status; Application for Immediate Family Member of T-1 Recipient; & Declaration of Law Enforcement Officer for Victim of Trafficking in Persons

OMB No. 1615-0099; Expires 02/29/2012

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

Department of Homeland Security
U.S. Citizenship and Immigration Services

Instructions
Read these instructions carefully to properly complete this form. If you need more space to complete an answer, use a separate
sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and
indicate the part and number of the item to which the answer refers.

What Is the Purpose of This Form?

3. Parent(s); or
4. Unmarried sibling(s) under the age of 18.

You should use Form I-914 to request temporary immigration
benefits if you are a victim of a severe form of trafficking in
persons.

B. If you are over the age of 21, qualifying family
members for whom you are filing are your:
1. Spouse; or

Who May File This Form?
2. Unmarried child(ren) under the age of 21.
Form I-914 should be filed by you, the victim of a severe form
of trafficking in persons, and may include qualifying family
members. It can also be used at a later date to file for
qualifying family members not included on the original
application.
1. Principal Applicant. You must demonstrate all of the
following:
A. You are or have been a victim of a severe form of
trafficking in persons;
B. You are 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 in persons;
C. You have complied with any reasonable request for
assistance in a Federal, State, or local investigation or
prosecution of acts of trafficking or the investigation of
crime where acts of trafficking are at least one central
reason for the commission of that crime, unless you are
under the age of 18; and
D. You would suffer extreme hardship involving unusual
and severe harm upon removal.
2. Principal Applicant concurrently filing for qualifying
family member, or currently holding T-1 nonimmigrant
status and filing for a qualifying family member. You
must also demonstrate that:
A. If you are under the age of 21, qualifying family
members for whom you are filing are your:
1. Spouse;
2. Unmarried child(ren) under the age of 21;

General Instructions
Fill Out Form I-914, Form I-914, Supplement A, and Form
I-914 , Supplement B (strongly encouraged).
1. Type or print legibly in black ink.
2. If extra space is needed to complete any item, attach a
continuation sheet, write your name and A-Number (if
any), indicate the item number, and date and sign each
sheet.
3. Answer all questions fully and accurately, unless instructed
to leave a part blank. State that an item is not applicable
with “N/A.” If the answer is none, write “None.”

Completing Form I-914
You, as the principal applicant, must file Form I-914 for
yourself.
This form is divided into Parts A through H. The following
information will help you fill out the form.
Part A. Purpose for Filing the Application - Check all
the appropriate boxes that apply to why you filed this
application.
Part B. General Information About You (person filing
this application as a victim of a severe form of trafficking
in persons)
1. Family Name (Last Name) - Give your legal name. If
you have two last names, include both and use a
hyphen (-) between the names, if appropriate.
Form I-914 Instructions (Rev. 02/01/11) Y

2. Given Name (First Name) - Give your full first name;
do not use "nicknames." (Example: If your name is
Albert, do not use Al.)

13. Country of Birth - Give the name of the country
where you were born. Include the city, state or
province, and country.

3. Other Names Used - Provide all the names you have
used, including maiden name if applicable, married
names, nicknames, etc.

14. Country of Citizenship - Give the name of the
country where you are a citizen. This is not necessarily
the country where you were born.

4. Home Address - Give your physical street address.
This must include a street number and name or a rural
route number. Do not put a post office box (P.O. Box)
number here.

15. Passport - Give the number of the passport used to
enter the United States, if applicable. Give the location
where your passport was issued. Give the date when
your passport was issued.

5. Safe Mailing Address - Give your mailing address, if
different from your home address. If you do not feel
secure in receiving correspondence regarding this
application at your home address, provide a "safe
mailing address" in this space. This address may be a
post office box, the address of a friend, your attorney,
a community-based organization that is helping you,
or any other address where you can safely and
punctually receive mail.

16. Last Entry Into the United States - Give the date
and place where you last entered the United States,
regardless of whether that entry was legal or illegal.

6. Home Telephone Number - Give the phone number
with area code. If you live outside the United States,
give the country and city code.
7. Safe Daytime Telephone Number - If you do not feel
secure in receiving telephone calls regarding this
application at your home telephone number, provide a
"safe telephone number" in this space. This number
may be for a friend, your attorney, a community-based
organization that is helping you, or any other number
where you can safely and punctually receive a call or a
message.
8. E-Mail Address - This is optional. If you do not have
an e-mail address or feel that your e-mail address is
not secure, write "None."
9. A-Number - This is your USCIS (former INS) file
number. If you do not have an A-Number or do not
know it, leave this blank.
10. U.S. Social Security Number - If you do not have a
Social Security Number, leave this blank.
11. Gender and Marital Status - Check the appropriate
box for each.
12. Date of Birth - Use eight numbers to show your date
of birth (example: May 1, 1979, should be written
(05/01/1979).

17. Form I-94, Arrival-Departure Document, Number
- If applicable, give the number on Form I-94 issued at
the time of entry.
18. Current Immigration Status - Give your current
status, regardless of how you entered the United States
(visitor, student, entry without inspection, etc.)
Part C. Additional Information
You must answer each question. You must explain
relevant information about your claim. Attach documents
in support of your claim and the specific facts on which
you are relying to support your claim.
Complete Question 11 to indicate whether you are
applying for one or more qualifying family members at
this time. See the next section below for information on
completing an application on behalf of your qualifying
family member.
Part D. Processing Information
You must answer each question. If you answer “Yes” to
any of the questions, explain on a separate sheet of paper.
Explain if any of the acts or circumstances relate to your
having been a victim of a severe form of trafficking in
persons.
Part E. Information about Your Family Members
Even if you are not applying to bring your family
member(s) to the United States, you must provide the
requested information about your spouse and children, if
any.

Form I-914 Instructions (Rev. 02/01/11) Y Page 2

Part F. Attestation, Release, and Signature
First read the information below regarding penalties. Then
you, the applicant, must sign and date the form. If you do
not sign the form, the application will be returned as
incomplete.
Part G. Preparer and/or Interpreter Certification
If you, the applicant, did not fill out Form I-914, the
preparer must also sign, date, and give his or her address.
Part H. Checklist
Fill out the checkboxes. This will ensure that you have
completed the form properly.

Completing Form I-914, Supplement A, Application
for Immediate Family Member of T-1 Recipient
If you are filing for a qualifying family member, you must
complete Form I-914, Supplement A, Application for
Immediate Family Member of T-1 Recipient. Form I-914,
Supplement A, must be submitted for each family member for
whom you are filing.
Form I-914, Supplement A, may be filed concurrently with the
principal applicant's initial Form I-914 or at any time
thereafter. However, any Form I-914, Supplement A,
submitted subsequently must have the appropriate boxes
checked in Part A, and must be accompanied by a copy of the
principal applicant's Form I-914. Evidence submitted with the
original application, however, need not be resubmitted.
This form is divided into Parts A through F. The following
information should help you fill out the form.
Part A. Family Member Relationship to You (the
principal)
Check the appropriate box.
Part B. Information About You
1. Family Name (Last Name) - Give your legal name. If
you have two last names, include both and use a hyphen
(-) between the names, if appropriate.
2. Given Name (First Name) - Give your full first name;
do not use "nicknames." (Example: If your name is
Albert, do not use Al.)
3. Date of Birth - Use eight numbers to show your date of
birth (example: May 1, 1979, should be written
05/01/1979).

4. A-Number - This is your USCIS (former INS) file
number. If you do not have an A-Number or do not
know it, leave this blank.
5. Status of your Form I-914, Application for T
Nonimmigrant Status - Check the appropriate box.
Part C. Information About Your Family Member (the
derivative)
1. Family Name (Last Name) - Give his or her legal
name. If he or she has two last names, include both and
use a hyphen (-) between the names, if appropriate.
2. Given Name (First Name) - Give his or her full first
name; do not use "nicknames." (Example: If his or her
name is Albert, do not use Al.)
3. Other Names Used - Provide all the names he or she
has used, including maiden name, if applicable, married
names, nicknames, etc.
4. Date of Birth - Use eight numbers to show his or her
date of birth (example: May 1, 1979, should be written
05/01/1979).
5. Country of Birth - Give the name of the country where
he or she was born. Include the city, state or province,
and country.
6. Country of Citizenship - Give the name of the country
where he or she is a citizen. This is not necessarily the
country where he or she was born.
7. Intended Address in the United States - Give his or
her intended physical street address. This must include
a street number and name or a rural route number. Do
not put a post office box (P.O. Box) number here.
8. Safe Mailing Address - Give his or her mailing
address, if different from his or her intended home
address. If he or she does not feel secure in receiving
correspondence regarding this application at his or her
home address, provide a "safe mailing address" in this
space. This address may be a post office box, the
address of a friend, your/his or her attorney, a
community-based organization, or any other address
where he or she can safely and punctually receive mail.
9. A Number - This is his or her USCIS (former INS) file
number. If he or she does not have an A-Number or you
do not know it, leave this blank.
10. U.S. Social Security Number - If he or she does not
have a U.S. Social Security Number, leave this blank.
Form I-914 Instructions (Rev. 02/01/11) Y Page 3

11. Form I-94, Arrival-Departure Document, Number
- If physically present in the United States, give the
number on Form I-94 issued at the time of entry.
12. Home Telephone Number - Give the telephone
number with area code where he or she lives and can
be reached during the day.
13. Safe Daytime Telephone Number - If he or she does
not feel secure receiving telephone calls regarding this
application at his or her home, provide a “safe
telephone number” in this space. This number may be
for a friend, his or her attorney, a community-based
organization, or any other number where he or she can
safely and punctually receive a call or a message.
14. Gender and Marital Status - Check the appropriate
box for each.
15. Passport - Give the number of the passport used to
enter the United States, if applicable. Give the location
where his or her passport was issued. Give the date
when his or her passport was issued.
16. Last Entry Into the United States - Give the date
and place where he or she last entered the United
States, regardless of whether that entry was legal or
illegal.

Part F. Preparer and/or Interpreter Certification
If you, the applicant, did not fill out Form I-914,
Supplement A, the preparer must also sign, date, and give
his or her address.

Completing Form I-914, Supplement B, Declaration
of Law Enforcement Officer for Victim of
Trafficking in Persons
Form I-914, Supplement B, is used by Federal, State, or local
law enforcement authorities to certify that you are a victim of
a severe form of trafficking in persons.
You are not required to file Form I-914, Supplement B, to
prove your claim. However, the endorsement of a Federal,
State, or local law enforcement authority is primary evidence
that you are a victim of a severe form of trafficking in persons
and that you have complied with any reasonable request for
assistance in the investigation or prosecution. These elements
of your claim may be difficult to establish otherwise, and
submission of Form I-914, Supplement B, is strongly advised.
Follow the additional instructions on Form I-914, Supplement
B.

Initial Evidence
You must submit:
1. A completed and signed Form I-914;

17. Immigration History - Give your family member's
immigration proceedings history, if any.
18. Employment Authorization - Mark the box whether
you are applying for employment authorization for
your family member. If "Yes," also submit Form
I-765, Application for Employment Authorization, for
your family member.
Part D. Processing Information
You must answer each question about your family
member. If you answer “Yes” to any of the questions,
explain on a separate sheet of paper.
Part E. Attestation, Release, and Signature
First read the information below regarding penalties. Then
you, the applicant, must sign and date the form. If you do
not sign the form, your application will be returned as
incomplete.
If the family member for whom you are filing is in the
United States, he or she must sign and date the form. If he
or she does not sign or date the form, then Form I-914,
Supplement A, will be returned as incomplete.

2. Evidence to establish each eligibility requirement (see next
section for details); and
3. Three identical color photographs of yourself taken within
30 days of the filing of this application. The photos must
have a white to off-white background, be printed on thin
paper with a glossy finish, and be unmounted and
unretouched. NOTE: Because of the current USCIS
scanning process, if a digital photo is submitted, it needs
to be produced from a high resolution camera, which
has at least a 3.5 mega pixel.
Passport-style photos must be 2" x 2." The photos must be
in color with full face, frontal view on a white to off-white
background. Head height should measure 1" to 1 3/8" from
top of hair to bottom of chin, and eye height is between 1
1/8" to 13/8" from bottom of photo. Your head must be
bare unless you are wearing a headdress as required by a
religious order of which you are a member. Using pencil or
felt pen, lightly print your name and A-Number on the
back of the photo.
If applying for your family member, you must also submit:
1. A completed and signed Form I-914, Supplement A,
Application for Immediate Family Member of a T-1
Form I-914 Instructions (Rev. 02/01/11) Y Page 4

Nonimmigrant, for each family member for whom you are
applying. You may file Form I-914, Supplement A,
concurrently with your initial application or at a later time.
Any Form I-914, Supplement A, submitted subsequent to
the principal applicant's initial filing, however, must be
accompanied by:
A. A new Form I-914 with the appropriate boxes checked
in Part A with an original signature in Part F; and
B. A copy of the original Form I-914.
2. Evidence to establish each eligibility requirement for each
family member (see next section for details).
NOTE: Evidence submitted with the original Form I-914
does not need to be resubmitted.
3. Three photographs of each family member (to comply with
the same requirements as the photographs of you).

Evidence to Establish T Nonimmigrant Status
You must file Form I-914 with evidence sufficient to
demonstrate that you satisfy each of the eligibility
requirements. If you have in your possession, or have access
to, a document showing how you entered the United States,
you must submit a copy of that document with your
application.
To qualify for T-1 nonimmigrant status, you must demonstrate
that you:
1. Are or have been a victim of a severe form of trafficking in
persons;
2. Are physically present in the United States, American
Samoa, or the Commonwealth of the Northern Mariana
Islands, or at a port of entry, as a result of trafficking;
3. Have complied with any reasonable request for assistance
in a Federal, State, or local law enforcement investigation
or prosecution of acts of trafficking in persons, unless you
are under 18 years old; and
4. Would suffer extreme hardship involving unusual and
severe harm upon removal.
To establish that you are or have been a victim of a severe
form of trafficking in persons, you must demonstrate that you
were brought to the United States either:
1. For the purpose of a commercial sex act, which was either
induced by force, fraud or coercion, or occurred when you
were under 18 years of age; or

2. For recruiting, harboring, transportation, provision, or
obtaining of a person for labor or services induced by
force, fraud, or coercion to subject you to involuntary
servitude, peonage, debt bondage, or slavery.

You are encouraged to raise all arguments and to document all
elements of your claim, including allegations of extreme
hardship, in your initial application.

Primary Evidence
Form I-914, Supplement B, Declaration of Law
Enforcement Officer for Victim of Trafficking in Persons
The primary evidence of your claim to be a victim of a severe
form of trafficking in persons shall be Form I-914,
Supplement B, Declaration of Law Enforcement Officer for
Victim of Trafficking in Persons. That declaration is appended
to this form.
You are not required to file Form I-914, Supplement B, to
prove your claim. However, the endorsement of a Federal,
State, or local law enforcement officer on Form I-914,
Supplement B, constitutes primary evidence that you are a
victim and that you have complied with any reasonable
request from a Federal, State, or local law enforcement
authority for assistance in the investigation or prosecution of
the acts of trafficking. These elements of your claim may be
difficult to establish otherwise, and submission of Form
I-914, Supplement B, is strongly advised. Instructions
pertinent to Form I-914, Supplement B, are appended to that
form.
If you do not provide a completed Form I-914, Supplement B,
you must submit an explanation, describing your attempts to
obtain the certification and why it does not exist or is
unavailable. If you did not attempt to obtain the certification,
you must explain why you did not.

Secondary Evidence
If you do not provide a completed Form I-914, Supplement B,
Declaration of Law Enforcement Officer for Victim of
Trafficking in Persons, in addition to the explanation
described above, you must also submit credible secondary
evidence to establish that you are or have been a victim of a
severe form of trafficking in persons and that you complied
with any reasonable request from law enforcement. Such
evidence may include, but is not limited to: police reports,
newspaper articles, witness affidavits, or any other form of
evidence. Even if you do provide Form I-914, Supplement B,
you may submit additional evidence.
Form I-914 Instructions (Rev. 02/01/11) Y Page 5

Personal Statement
Including a personal narrative statement is strongly
encouraged. That statement should describe the trafficking
crime of which you were a victim, including:
1. The circumstances of your entry into the United States;
2. The purpose for which you were brought to the United
States;
3. How you were recruited or otherwise became involved in
the trafficking situation;
4. When these events took place;
5. Who was responsible;
6. How long you were detained by the traffickers;
7. How and when you escaped, were rescued, or otherwise
became separated from the traffickers;
8. What you have been doing since you were separated from
the traffickers;
9. Why you were unable to leave the United States after you
were separated from the traffickers;
10. What harm or mistreatment you fear if you are removed
from the United States; and
11. Why you fear you would be harmed or mistreated.

Evidence to Establish Derivative T
Nonimmigrant Status
You, as the principal applicant or as current T-1 nonimmigrant
status holder filing for your family members, must file Form
I-914, Supplement A, with evidence sufficient to demonstrate
that your family members satisfy each of the eligibility
requirements.
If you are under the age of 21, qualifying family members for
whom you are filing must be your:
1. Spouse;
2. Unmarried child(ren) under the age of 21;
3. Parent(s); or
4. Unmarried sibling(s) under the age of 18.

If you are over the age of 21, qualifying family members for
whom you are filing are your:
1. Spouse; or
2. Unmarried child(ren) under the age of 21.
You must include:
1. A completed Form I-914, Supplement A, Application for
Immediate Family Member of T-1 Recipient, for each
qualifying family member you want included on your
application.
2. Credible documentation of the claimed relationship.
Documents acceptable for this purpose are:
If you are filing for your:
A. Husband or Wife - Submit a copy of your marriage
certificate issued by a civil authority.
If either you or your spouse were married before, you
must submit documents to show all previous marriages
were legally terminated. (Example: a divorce decree or
death certificate.)
B. Child and you are the mother - Submit a copy of the
child's birth certificate showing your name and the
name of the child issued by a civil authority.
C. Child and you are the father - Submit a copy of the
child's birth certificate issued by a civil authority
showing both parents' names and your marriage
certificate. If the child was born out of wedlock, give
proof that a parent-child relationship exists or existed.
(Example: the child's birth certificate showing your
name and evidence that you have financially supported
the child. In some cases, a blood test may be
necessary.)
D. Mother - Submit a copy of your birth certificate issued
by a civil authority showing your name and your
mother's name.
E. Father - Submit a copy of your birth certificate
showing the names of both parents, your parents'
marriage certificate establishing that your father was
married to your mother before you were born, and
copies of documents showing that any prior marriages
of either your father or mother were legally terminated.
If you are filing for a stepparent or adoptive parent, or
if you are filing for your father and were not
legitimated before your 18th birthday, also see C, G,
and H.

Form I-914 Instructions (Rev. 02/01/11) Y Page 6

F. Brother or Sister - Submit a copy of your birth
certificate and a copy of your brother's or sister's birth
certificate showing that you have at least one
common parent. If you and your brother or sister have
a common father but different mothers, submit copies
of the marriage certificates of the father to each
mother and copies of documents showing that any
prior marriages of either your father or mother were
legally terminated. If you and your brother or sister
are related through adoption or through a stepparent,
or if you have a common father and either of you
were not legitimated before your 18th birthday, see
also G and H.
G. Stepparent/Stepchild - If your application is based on
a stepparent-stepchild relationship, you must file your
application with a copy of the marriage certificate of
the stepparent to the child's natural parent showing that
the marriage occurred before the child's 18th birthday,
and copies of documents showing that any prior
marriages were legally terminated.
H. Adoptive parent or adopted child - If you and the
person you are filing for are related by adoption, you
must submit a copy of the adoption decree(s) showing
that the adoption took place before the child became 16
years of age.

NOTE: USCIS may require a statement from the appropriate
civil authority certifying that the necessary document is
unavailable.
1. Church record: A certificate under the seal where the
baptism, dedication, or comparable rite occurred within
two months after the birth, showing the date and place of
the child's birth, date of the religious ceremony, and the
names of the child's parents.
2. School record: A letter from the authority of the school
attended (preferably the first school) showing dates of
admission to the school, child's date and place of birth, and
the names and birthplaces of both parents if shown in the
school records.
3. Census records: Federal or State census records showing
the names place of birth and date of birth or age of the
person listed.
4. Affidavits: Written statements sworn to or affirmed by
two persons who were living at the time and who have
personal knowledge of the event you are trying to prove.
(Example: the date and place of birth, marriage, divorce, or
death.) The persons making the affidavits need not be
citizens of the United States. Each affidavit should contain
the following information:
A. The relationship, if any, between you and the affiant;

If the relationship was created by the adoption of the
sibling of a child already adopted, then you must
submit a copy of the adoption decree(s) showing that
the adoption of the sibling took place before the child
became 18 years of age.
In either case, you also must submit copies of evidence
showing that each child was in the legal custody of and
resided with the parent(s) who adopted him or her for
at least two years before or after the adoption. Legal
custody may only be granted by a court or recognized
government entity and is usually granted at the time the
adoption is finalized. However, if legal custody is
granted by a court or recognized government agency
prior to the adoption, that time may count to fulfill the
two-year legal custody requirement.
I. Your unmarried sibling under age 18 - Submit a
certified copy of your birth certificate and a copy of
your brother's or sister's birth certificate showing that
you have at least one common parent.
Unavailable Documents
If a required document is not available, you may give USCIS
the following secondary evidence instead:

B. Full information concerning the event; and
C. Complete details concerning how the person acquired
knowledge of the event.
NOTE: In a case where you or your relative's name has
changed from what is shown on the supporting document,
submit the legal document authorizing such name change.
(Example: marriage certificate, adoption decree, court
order, etc.)

Waiver of Ground(s) of Inadmissibility
To be eligible for T nonimmigrant status, you must be
admissible to the United States. If you or your qualifying
family member(s) answered "Yes" to one or more of the
questions in Part D of Form I-914 or Form I-914, Supplement
A, you or your qualifying family member(s) may be
inadmissible.
If you and/or your qualifying family member(s) is or becomes
inadmissible under section 212(a) of the Immigration and
Nationality Act, you and/or your family member(s) will not be
eligible for T nonimmigrant status unless the ground of
inadmissibility is waived by USCIS.
Form I-914 Instructions (Rev. 02/01/11) Y Page 7

Applicants seeking a waiver of inadmissibility must submit
Form I-192, Application for Advance Permission to Enter as a
Nonimmigrant (Pursuant to Section 212(d)(3) of the
Immigration and Nationality Act). A separate fee or request
for fee waiver must be filed with Form I-192. Form I-192
should be filed concurrently with Form I-914. USCIS, in its
discretion, will decide eligibility for the waiver.

Initial Processing
Once Form I-914 has been accepted, it will be checked for
completeness, including submission of the required initial
evidence. If you do not completely fill out the form or file it
without required initial evidence, you will not establish a basis
for eligibility, and we may deny your Form I-914.
Requests For More Information or Interview

Where to File?
Mail your complete application to the following address:
USCIS
Vermont Service Center
75 Lower Welden Street
St. Albans, VT 05479-0001

What Is the Filing Fee?
There is no filing fee for Form I-914.
No biometrics services fee is required.

Address Changes
If you change your address and you have an application or
petition pending with USCIS, you may change your address
online at www.uscis.gov. Click on "Change your address with
USCIS" and follow the prompts, or you may complete and
mail Form AR-11, Alien's Change of Address Card, to:
U.S. Citizenship and Immigration Services
Change of Address
P.O. Box 7134
London, KY 40742-7134
For commercial overnight or fast freight services only, mail to:
U.S. Citizenship and Immigration Services
Change of Address
1084-I South Laurel Road
London, KY 40744

Processing Information
Any Form I-914 that is not signed will be rejected with a
notice that Form I-914 is deficient. You may correct the
deficiency and resubmit Form I-914. An application is not
considered properly filed until accepted by USCIS.

We may request more information or evidence, or we may
request that you appear at a USCIS office for an interview. We
may also request that you submit the originals of any copy.
Employment Authorization
If your application is approved, you will be authorized
employment, and USCIS will send you an Employment
Authorization Document as evidence of that authorization.
Derivative family members are also authorized employment.
If they wish to obtain an Employment Authorization
Document as evidence of authorization, Form I-765,
Application for Employment Authorization Document, with
appropriate fee, may be filed concurrently with Form I-914
and Form I-914, Supplement A.
Derivative family members living outside the United States
are not eligible to receive employment authorization until they
lawfully enter the United States. Do not file Form I-765 for a
derivative family member who is outside the United States.
Decision
The decision on Form I-914 involves a determination of
whether you have established eligibility for the requested
benefit. You will be notified of the decision in writing.
Confidentiality
Information provided in the application is confidential and
protected from disclosure. It will be used to determine
eligibility, to investigate fraudulent claims, to enforce
penalties for false statements, to assist in the investigation and
prosecution of trafficking and related crimes but for no other
purpose. The information provided is subject to verification
by USCIS. Adverse determination of admissibility or
deportability cannot be made based on information obtained
from the trafficker. The disclosure of information relating to a
pending or approved application for T nonimmigrant status is
prohibited except in certain circumstances, such as to
investigative agencies who have a reason to know based on a
legitimate law enforcement purpose.

Form I-914 Instructions (Rev. 02/01/11) Y Page 8

USCIS Forms and Information
To order USCIS forms, call our toll-free number at
1-800-870-3676. You can also get USCIS forms and
information on immigration laws, regulations, and procedures
by telephoning our National Customer Service Center at
1-800-375-5283 or visiting our Internet Web site at www.
uscis.gov.
As an alternative to waiting in line for assistance at your local
USCIS office, you can now schedule an appointment through
our Internet-based system, InfoPass. To access the system,
visit our Web site. Use the InfoPass appointment scheduler
and follow the screen prompts to set up your appointment.
InfoPass generates an electronic appointment notice that
appears on the screen.

Penalties
If you knowingly and willfully falsify or conceal a material
fact or submit a false document with your Form I-914, we will
deny Form I-914 and may deny any other immigration benefit.
In addition, you will face severe penalties provided by law and
may be subject to criminal prosecution.

Privacy Act Notice
We ask for the information on this form, and associated
evidence, to determine if you have established eligibility for
the immigration benefit for which you are filing. Our legal
right to ask for this information can be found in the
Immigration and Nationality Act, as amended. We may
provide this information to other government agencies. Failure
to provide this information, and any requested evidence, may
delay a final decision or result in denial of your Form I-914.

Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
collection of information is estimated at 3 hours and 15
minutes per response, including the time for reviewing
instructions, completing and submitting the form. Send
comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for
reducing this burden, to: U.S. Citizenship and Immigration
Services, Regulatory Products Division, Office of the
Executive Secretariat, 20 Massachusetts Avenue, N.W.,
Washington, DC 20529-2210. OMB No. 1615-0099. Do not
mail your application to this address.

Form I-914 Instructions (Rev. 02/01/11) Y Page 9