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pdfSupplement A to Form I-914, Application for Derivative T
Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in ink. See Instructions for information about
eligibility and how to complete and file this application. The recipient of the T
nonimmigrant classification is referred to as the principal applicant. Their family
member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be
completed by the principal applicant.
USCIS
Form I-914
OMB No. 1615-0099
Expires 02/28/2026
For USCIS Use Only
Returned
Receipt
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Date
Date
PART 1. Family Member For Whom You are Filing
1.
The family member that I am filing for is my (select only one box):
Spouse
Resubmitted
Date
Date
Child
Reloc Sent
Parent
Date
Unmarried Sibling Under 18 Years of Age
2.
The family member I am filing for is the adult or minor child of one of the family
members listed in Item Number 1. who faces a present danger of retaliation as a
result of my escape from the severe form of trafficking in persons or my cooperation
with law enforcement and is the adult or minor (select only one box.)
Date
Reloc Rec'd
Date
Date
Child of my spouse
Validity Dates
Child of my child (my grandchild)
From:
To:
Child of my parent (my sibling over 18 years of age)
Child of my unmarried sibling under 18 years of age (my niece or nephew)
Remarks
PART 2. General Information About You (the principal)
1.
Your Full Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any )
Waitlisted
2.
Date of Birth (mm/dd/yyyy)
3.
Alien Registration Number (A-Number)
Stamp #
► A-
Date
Action Block
4.
Status of your Form I-914, Application for T Nonimmigrant Status: (Select one)
Filing this Form I-914, Supplement A, together
Pending
Approved
PART 3. Information About Your Family Member (the derivative)
1.
Your Full Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
To be fully completed by an attorney or
accredited representative, if any.
Select this box if Form G-28 is attached.
Attorney State License Bar Number
Attorney or Accredited Representative
USCIS Online Account Number
Form I-914 Supp A Edition 04/01/24
Page 1 of 12
PART 3. Information About Your Family Member (the derivative) (continued)
2.
Other Names Used
Provide any other names your family member has used since birth, including aliases, maiden names, and nicknames. If you need
extra space to complete this section, use the space provided in Part 8. Additional Information.
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Family Name (Last Name)
3.
4.
Given Name (First Name)
Middle Name (if any)
U.S. Physical Address or Intended Physical Address
(USCIS ZIP Code Lookup)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
Safe U.S. 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
5.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Alien Registration Number (A-Number) (if any)
6.
USCIS Online Account Number
►
8.
Gender
Male
► A7.
9.
U.S. Social Security Number (SSN) (if any)
►
Female
ZIP Code
Another Gender Identity
Marital Status
Single/Never Married
Married
Divorced
Widowed
Annulled
10. If your family member was previously married, list names of prior spouses and dates of termination of marriage. Documents such
as divorce decrees or death certificates must be attached. If you need extra space to complete this section, use the space provided
in Part 8. Additional Information.
A. Name of Former Spouse
Family Name (Last Name)
Given Name (First Name)
Middle Name
B. Date Marriage Ended (mm/dd/yyyy)
Form I-914 Supp A Edition 04/01/24
Page 2 of 12
PART 3. Information About Your Family Member (the derivative) (continued)
C. Where Marriage Ended
City or Town
State or Province
Country
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D. How Marriage Ended
Annulled
Divorced
Separated
Widowed
11. Date of Birth (mm/dd/yyyy)
12. Place of Birth
City or Town
State or Province
Country
13. Country of Citizenship or Nationality
14. Passport or Travel Document Number
15. Country That Issued Passport or Travel Document
16. Issued Date for Passport or Travel Document
(mm/dd/yyyy)
17. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
18.
Current Immigration Status
19. Is your family member currently living in the United States?
Yes
No
20. If you answered “Yes” to Item Number 19., give the following information about your family member if they are currently in the
United States.
A. Place of Last Entry
City or Town
B. Date of Last Entry (mm/dd/yyyy)
State
C. Form I-94 Arrival-Departure Record Number
►
21. If your family member is outside the United States, indicate the U.S. Consulate or inspection facility you want notified if this
application is approved.
A. Type of Office (Select one):
Consulate
Pre-flight Inspection Facility
B. City or Town
Form I-914 Supp A Edition 04/01/24
Port of Entry
C. U.S. State or Foreign Country
Page 3 of 12
PART 3. Information About Your Family Member (the derivative) (continued)
D. Foreign Address Where You Want Notification Sent
Street Number and Name
Apt. Ste. Flr. Number
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City or Town
Province
State
Postal Code
ZIP Code
Country
22. Give the following information about your family member if they have previously traveled to the United States.
A. Place of Entry
City or Town
B. Date of Entry (mm/dd/yyyy)
State
C. Date Authorized Stay Expired
(mm/dd/yyyy)
D. Immigration Status
23. Has your family member ever been in immigration court proceedings?
Yes
No
Yes
No
24. If you answered “Yes” to Item Number 23., what type of proceedings? (Select all that apply)
A.
Removal Date (mm/dd/yyyy)
B.
Exclusion Date (mm/dd/yyyy)
C.
Deportation Date (mm/dd/yyyy)
D.
Recission Date (mm/dd/yyyy)
E.
Next Hearing Date (mm/dd/yyyy)
25. Is your family member requesting an Employment Authorization Document?
If you answered “Yes” to Item Number 25., submit Form I-765, Application for Employment
Authorization Document, with Form I-914, Supplement A, or separately.
NOTE: If your family member is living outside the United States, they are not eligible to receive
employment authorization until they are lawfully admitted to the United States. Do not file Form I-765 for
a family member living outside the United States.
Form I-914 Supp A Edition 04/01/24
Page 4 of 12
PART 4. Processing Information
Answer the following questions about your family member for whom you are filing. You must answer “Yes” to the following
questions even if the records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney
told you that your family member no longer has a record. (If your answer is “Yes” to any one of these questions, use the space
provided in Part 8. Additional Information to explain your answer. Answering “Yes” does not necessarily mean that your family
member will be denied T nonimmigrant status.)
1.
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Has the family member for whom you are filing EVER:
A. Committed a crime or offense for which they 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.
Yes
No
Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?
If you answered “Yes” to any part of Item Number 1., complete the following table. If you need extra space to complete this
section, use the space provided in Part 8. Additional Information to explain your answer.
Why was the family member for whom
Date of arrest,
Where was the family member
Outcome or disposition
you are filing arrested, cited, detained,
citation,
for whom you are filing arrested, (for example, no charges
or charged?
detention, charge
cited, detained, or charged?
filed, charges dismissed, jail,
(mm/dd/yyyy)
(City or Town, State, Country)
probation, etc.)
2.
Has the family member for whom you are filing:
A. Engaged in prostitution or procurement of prostitution or does he or she 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 Supp A Edition 04/01/24
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PART 4. Processing Information (continued)
3.
Has the family member for whom you are filing 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.
4.
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
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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
Has the family member for whom you are filing 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?
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
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.
Has the family member for whom you are filing EVER been or do they continue to be a member of the
Communist or other totalitarian party, except when membership was involuntary?
Yes
No
7.
Has the family member for whom you are filing, 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
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:
5.
Does the family member for whom you are filing intend to engage in the United States in:
A.
Espionage?
Form I-914 Supp A Edition 04/01/24
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PART 4. Processing Information (continued)
8.
9.
Has the family member for whom you are filing EVER been present or nearby when any person was:
A. Intentionally killed, tortured, beaten, or injured?
Yes
No
B. Displaced or moved from their residence by force, compulsion, or duress?
Yes
No
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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 the family member for
whom you are filing?
Yes
No
B. Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the
family member for whom you are filing?
Yes
No
C. Has the family member for whom you are filing EVER been removed, excluded, or deported from the
United States?
Yes
No
D. Has the family member for whom you are filing EVER been ordered to be removed, excluded, or
deported from the United States?
Yes
No
E. Has the family member for whom you are filing EVER been denied a visa or denied admission to the
United States? (If a visa was denied, use the space provided in Part 8. Additional Information to
explain your answer.)
Yes
No
F.
Yes
No
Has the family member for whom you are filing EVER been granted voluntary departure by an
immigration officer or an immigration judge and failed to depart within the allotted time?
10. Has the family member for whom you are filing (or has any member of their family) 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
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. Has the family member for whom you are filing EVER been a member of, assisted in, or participated in
any group, unit, or organization of any kind in which they or any other persons used any type of weapon
against any person or threatened to do so?
Yes
No
13. Has the family member for whom you are filing EVER assisted or participated in selling or providing
weapons to any person who to their knowledge used them against another person, or in transporting
weapons to any person who to their knowledge used them against another person?
Yes
No
14. Has the family member for whom you are filing EVER received any type of military, paramilitary, or
weapons training?
Yes
No
15. Is the family member for whom you are filing under a final order or civil penalty for violating INA section
274C (producing and/or using false documentation to unlawfully satisfy a requirement of the INA)?
Yes
No
16. Has the family member for whom you are filing 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
11. Has the family member for whom you are filing EVER:
Form I-914 Supp A Edition 04/01/24
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PART 4. Processing Information (continued)
17. Has the family member for whom you are filing EVER left the United States to avoid being drafted into
the U.S. Armed Forces?
Yes
No
18. Has the family member for whom you are filing 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. Does the family member for whom you are filing plan to practice polygamy in the United States?
Yes
No
20. Did the family member for whom you are filing enter the United States as a stowaway?
Yes
No
21. A. Does the family member for whom you are filing have a communicable disease of public health
significance?
Yes
No
B. Does the family member for whom you are filing have or have they 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 themselves or others?
Yes
No
C. Is the family member for whom you are filing now or have they been a drug abuser or drug addict?
Yes
No
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PART 5. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
NOTE: Read the Penalties section of the Form I-914 Instructions before completing this part.
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.
B.
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.
The interpreter named in Part 6. 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 7.,
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 Supp A Edition 04/01/24
4.
Applicant's Mobile Telephone Number (if any)
Page 8 of 12
PART 5. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S.
Citizenship and Immigration Services (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.
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I authorize the release of any information from my record that USCIS needs to determine eligibility for the benefit I am seeking for
the family member for whom I am applying, 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 U.S.C. 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. Any disclosure shall be
in accordance with the confidentiality provisions at 8 U.S.C. section 1367 and 8 CFR 214.216.
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.
NOTE: If your family member is in the United States, they must verify the accuracy of the information recorded on this supplement
and must also complete this section of the supplement.
Applicant's Signature
6.
Applicant's Signature
Applicant's Phone Number (if any)
7.
Date of Signature (mm/dd/yyyy)
Applicant's Safe Phone Number (if any)
Signature of Family Member (the family member for whom you are filing if they are physically Date of Signature (mm/dd/yyyy)
present in the United States)
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 6. Interpreter's Contact Information, Certification, and Signature
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)
Form I-914 Supp A Edition 04/01/24
Interpreter's Given Name (First Name)
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PART 6. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
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City or Town
Province
State
Postal Code
ZIP Code
Country
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 5., 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
their answer to every question. The applicant informed me that they understand 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 7. 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)
Form I-914 Supp A Edition 04/01/24
Preparer's Given Name (First Name)
Page 10 of 12
PART 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
Preparer's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
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Province
Postal Code
ZIP Code
Country
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.
B.
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.
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 they understand all of the information contained in, and submitted with,
their 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 Supp A Edition 04/01/24
Date of Signature (mm/dd/yyyy)
Page 11 of 12
Part 8. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Type or print 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; and sign and date each sheet.
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1.
Family Name (Last Name)
2.
A-Number
3.
A. Page Number
D.
4.
A. Page Number
D.
5.
A. Page Number
Given Name (First Name)
Middle Name
► A-
B. Part Number
C. Item Number
B. Part Number
C. Item Number
B. Part Number
C. Item Number
B. Part Number
C. Item Number
D.
6.
A. Page Number
D.
Form I-914 Supp A Edition 04/01/24
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| File Type | application/pdf |
| File Title | Form I-914, Supplement A, Application for Family Member of T-1 Recipient |
| Author | USCIS |
| File Modified | 2024-07-08 |
| File Created | 2024-07-08 |