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4]
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Part
4. Processing
Information
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.
[Table
with 4 columns, 2 rows]
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
or Town,
State,
Country)
Outcome
or
disposition
(for
example,
no
charges filed, charges dismissed,
jail,
probation,
etc.)
2.
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
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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
individuals
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
the
Immigration
and
Nationality
Act
section
219?
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:
(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 individuals
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
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
No
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6]
8.
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
their
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
9.
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
10.
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
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?
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
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21.
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
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