Form I-914 - Supplement A, Application For Family Member Of T-1 Recipient - U.s. Citizenship And Immigration Services

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Supplement A, Application for Family
USCIS
Member of T-1 Recipient
Form I-914
Department of Homeland Security
OMB No. 1615-0099
U.S. Citizenship and Immigration Services
Expires 01/31/2019
START HERE - Type or print. Use black ink. See Instructions for information about
For USCIS Use Only
eligibility and how to complete and file this application. The recipient of the T
Returned
Receipt
nonimmigrant classification is referred to as the principal applicant. His or her family
member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be
Date
completed by the principal applicant.
Date
PART A. Family Member Relationship to You (the principal)
Resubmitted
The family member that I am filing for is my: (Check one)
Date
Husband/Wife
Child
Parent
Unmarried Sibling Under 18 Years of Age
Date
Reloc Sent
PART B. Family Member Relationship to Your Derivative
Date
The family member I am filing for is the adult or minor child of my derivative (my
grandchild, my spouse's child, my niece or nephew, or my sibling) who faces a present
Date
danger of retaliation as a result of my escape from the severe form of trafficking in persons
Reloc Rec'd
or my cooperation with law enforcement.
Date
Derivative's Adult
OR
Minor Child
Date
PART C. General Information About You (the principal)
Validity Dates
From:
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
To:
Date of Birth (mm/dd/yyyy)
A-Number (if any)
Remarks
Status of your Form I-914, Application for T Nonimmigrant Status: (Check one)
Filing this Form I-914, Supplement A, concurrently
Pending
Approved
Conditional Approval
PART D. Information About Your Family Member (the derivative)
Stamp #
Date
Action Block
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Other Names Used (include maiden name/nickname)
Residence or Intended Residence in the U.S. - Street Number and Name Apt. Number
City
State
ZIP Code
To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the applicant.
ATTY State
License #
Form I-914, Supplement A 02/27/17 Y
Page 1

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