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pdfUSCIS
Form I-914
Application for T Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0099
Expires 04/30/2021
START HERE - Type or print in ink.
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For USCIS Use Only
Part 1. Purpose for Filing This Application
Returned
Select all applicable boxes.
Date
1.
A.
I am filing for T-1 nonimmigrant status and have not previously filed for
such status.
Date
B.
I am filing for T-1 nonimmigrant status and have previously filed for
such status. (Provide receipt number below.)
Date
(1)
Reloc Sent
Your Full Legal Name
Family Name (Last Name)
2.
Given Name (First Name)
Middle Name (if any)
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 9. Additional Information.
3.
Physical Address
Street Number and Name
City or Town
4.
Date
Date
Reloc Rec'd
Date
Date
Other Names Used
Family Name (Last Name)
Resubmitted
Date
Receipt Number EAC
Part 2. General Information About You (Person filing this application as a victim)
1.
Receipt
Given Name (First Name)
Validity Dates
From:
To:
Remarks
Middle Name (if any)
(USPS ZIP Code Lookup)
Apt. Ste. Flr. Number
State
ZIP Code
Conditional Approval
Stamp #
Date
Action Block
Safe Mailing Address
If you do not want U.S. Citizenship and Immigration Services (USCIS) to send
notices about this application to your home address, you may provide an alternate
safe mailing address.
In Care Of Name
Street Number and Name
Apt. Ste. Flr. Number
To be fully completed by an attorney or
accredited representative, if any.
Select this box if Form G-28 is attached.
City or Town
State
ZIP Code
Attorney State License Bar Number
Attorney or Accredited Representative
USCIS Online Account Number
Form I-914 Edition 10/02/20
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Part 2. General Information About You (Person filing this application as a victim) (continued)
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5.
Alien Registration Number (A-Number) (if any)
► A-
6.
USCIS Online Account Number (if any)
►
7.
U.S. Social Security Number (SSN) (if any)
►
8.
Gender
9.
Marital Status
Single/Never Married
11.
Place of Birth
City or Town
Country
Male
Female
10.
Married
Divorced
Date of Birth (dd/mm/yyyy)
Widowed
State or Province
12.
Country of Citizenship or Nationality
13.
14.
Country That Issued Your Passport or Travel Document (if any) 15.
Passport or Travel Document Number (if any)
Issue Date for Passport or Travel Document (if any)
(mm/dd/yyyy)
16.
Expiration Date for Passport or Travel Document (if any)
(mm/dd/yyyy)
17.
Place of Your Last Entry Into the United States
City or Town
18.
Date of Your Last Entry Into the United States, On or About
State
19.
(mm/dd/yyyy)
20.
Form I-94 Arrival-Departure Record Number (if any)
►
Your Current Nonimmigrant Status
Part 3. Additional Information About Your Application
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 addressing the eligibility requirements for T
nonimmigrant status as listed in the regulations, including a description of the trafficking you experienced. If you need extra space to
complete this section, use the space provided in Part 9. Additional Information.
1.
I am or have been a victim of a severe form of trafficking in persons.
(Attach evidence to support your claim.)
Yes
No
2.
A.
I have cooperated with reasonable requests for assistance from law enforcement.
Yes
No
B.
Due to my age or the trauma I have suffered, I am exempt from the requirement to cooperate with
reasonable requests for assistance from law enforcement.
Yes
No
Form I-914 Edition 10/02/20
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Part 3. Additional Information About Your Application (continued)
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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 you selected “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 you selected
“Yes,” explain in detail and attach evidence and documents supporting this claim.)
Yes
No
5.
I have reported the trafficking crime of which I am claiming to be a victim. (If you selected “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 you selected “No,” explain the circumstances.)
Yes
No
Law Enforcement Agency and Office
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Daytime Telephone Number
Circumstances
ZIP Code
Case Number
6.
I am under 18 years of age. (If you selected "Yes," skip to Item Number 8.)
Yes
No
7.
I have complied with reasonable requests from Federal, state, local, or tribal 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 you selected “No,” explain the circumstances.)
Yes
No
8.
This is the first time I have entered the United States. (If you selected “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.) If you need extra space, use the space provided in Part 9. Additional
Information.
Yes
No
(1)
Date of Entry (mm/dd/yyyy)
(2)
Place of Entry
City or Town
(3)
State
Status
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 am requesting an Employment Authorization Document (EAD).
Yes
No
11.
I am now applying for one or more eligible family members. (If you selected “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.)
Yes
No
Form I-914 Edition 10/02/20
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Part 4. Processing Information
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Answer the following questions about yourself. Responses are intended to cover any activity you have committed under your legal
name or any aliases. For purposes of this application, 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 in the space provided in Part 9. Additional Information.
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.)
1.
Have you EVER:
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 Department of Homeland
Security (DHS), former Immigration and Naturalization Service (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?
Yes
No
If you answered “Yes” to any of the above questions, complete the following table. If you need extra
space, use the space provided in Part 9. Additional Information.
Why were you arrested, cited,
detained, or charged?
2.
Date of arrest,
citation, detention,
charge
(mm/dd/yyyy)
Where were you arrested,
cited, detained, or charged?
(City or Town, State,
Country)
Outcome or disposition
(for example, no charges
filed, charges dismissed,
jail, probation, etc.)
Have you:
A.
Engaged in prostitution or procurement of prostitution or do you intend to engage in prostitution or
procurement of prostitution?
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?
Yes
No
Form I-914 Edition 10/02/20
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Part 4. Processing Information (continued)
3.
4.
5.
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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
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 the Immigration and Nationality Act section 219?
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:
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
(3)
Assassination?
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
(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?
Yes
No
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
No
Form I-914 Edition 10/02/20
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Part 4. Processing Information (continued)
8.
9.
10.
11.
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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
A.
Are removal, exclusion, rescission, or deportation proceedings pending against you?
Yes
No
B.
Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against you?
Yes
No
C.
Have you EVER been removed, excluded, or deported from the United States?
Yes
No
D.
Have you EVER been ordered to be removed, excluded, or deported from the United States?
Yes
No
E.
Have you EVER been denied a visa or denied admission to the United States? (If a visa was denied,
use the space provided in Part 9. Additional Information.)
Yes
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?
Yes
No
Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
A.
Acts involving torture or genocide?
Yes
No
B.
Killing any person?
Yes
No
C.
Intentionally and severely injuring any person?
Yes
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
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?
Yes
No
B.
Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that
involved detaining persons?
Yes
No
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?
Yes
No
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?
Yes
No
14.
Have you EVER received any type of military, paramilitary, or weapons training?
Yes
No
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)?
Yes
No
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?
Yes
No
17.
Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?
Yes
No
18.
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
19.
Do you plan to practice polygamy in the United States?
Yes
No
20.
Have you entered the United States as a stowaway?
Yes
No
Form I-914 Edition 10/02/20
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Part 4. Processing Information (continued)
21.
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A.
Do you have a communicable disease of public health significance?
Yes
No
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?
Yes
No
C.
Are you now or have you been a drug abuser or drug addict?
Yes
No
Part 5. Information About Your Family Members
Provide the following information about your spouse and all of your children, if applicable. If you need extra space to complete this
section, use the space provided in Part 9. Additional Information.
1.
Your Spouse's Legal Name
Family Name (Last Name)
2.
Date of Birth (mm/dd/yyyy)
4.
Current Location
Given Name (First Name)
3.
Country of Birth
City or Town of Residence
5.
Middle Name (if any)
Country of Residence
Information About Your Children
A.
Child 1
Family Name (Last Name)
Given Name (First Name)
Date of Birth (mm/dd/yyyy) Country of Birth
Middle Name (if any)
Relationship
Current Location
City or Town
B.
State
Country
Child 2
Family Name (Last Name)
Given Name (First Name)
Date of Birth (mm/dd/yyyy) Country of Birth
Middle Name (if any)
Relationship
Current Location
City or Town
Form I-914 Edition 10/02/20
State
Country
Page 7
Part 5. Information About Your Family Members (continued)
C.
Child 3
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Family Name (Last Name)
Given Name (First Name)
Date of Birth (mm/dd/yyyy) Country of Birth
Middle Name (if any)
Relationship
Current Location
City or Town
State
Country
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 for derivative T nonimmigrant status, and attach it to this application.
Part 6. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
NOTE: Read the Penalties section of the Form I-914 Instructions before completing this section.
Applicant's Statement
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.
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.
B.
The interpreter named in Part 7. read to me every question and instruction on this application and my answer to every
question in
,
a language in which I am fluent, and I understood everything.
2.
Applicant's Statement Regarding the Preparer
At my request, the preparer named in Part 8.,
prepared this application for me based only upon information I provided or authorized.
,
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
5.
Applicant's Email Address (if any)
Form I-914 Edition 10/02/20
4.
Applicant's Safe Daytime Telephone Number
Page 8
Part 6. Applicant's Statement, Contact Information, Declaration, Certification, and Signature (continued)
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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 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).
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:
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.
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.
Applicant's Signature
6.
Applicant's Signature
Date of Signature (mm/dd/yyyy)
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.
Part 7. Interpreter's Contact Information, Certification, and Signature (if any)
Provide the following information about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
2.
Interpreter's Business or Organization Name (if any)
Interpreter's Given Name (First Name)
Interpreter's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Form I-914 Edition 10/02/20
Postal Code
ZIP Code
Country
Page 9
Part 7. Interpreter's Contact Information, Certification, and Signature (if any) (continued)
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Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
6.
Interpreter's Email Address (if any)
5.
Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language specified in Part 6., Item B. in
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.
Interpreter's Signature
7.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
1.
Preparer's Family Name (Last Name)
2.
Preparer's Business or Organization Name (if any)
Preparer's Given Name (First Name)
Preparer's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Form I-914 Edition 10/02/20
Postal Code
ZIP Code
Country
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Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
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Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
6.
Preparer's Email Address (if any)
5.
Preparer's Mobile Telephone Number (if any)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.
B.
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.
extends
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.
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
Form I-914 Edition 10/02/20
Date of Signature (mm/dd/yyyy)
Page 11
Part 9. Additional Information
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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 your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to
which your answer refers.
1.
Family Name (Last Name)
2.
A-Number ► A-
3.
A.
D.
4.
A.
D.
5.
A.
Given Name (First Name)
Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
Middle Name
D.
6.
A.
D.
Form I-914 Edition 10/02/20
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| File Type | application/pdf |
| File Title | Form I-914, Application for T Nonimmigrant Status |
| Author | USCIS |
| File Modified | 2021-02-17 |
| File Created | 2021-02-17 |