Form I-914 - Supplement A, Application For Family Member Of T-1 Recipient - U.s. Citizenship And Immigration Services Page 2

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PART D. Information About Your Family Member (the derivative) (continued)
Safe Mailing Address (if other than above) - Street Number and Name
Apt. Number
C/O (in care of):
City
State/Province
ZIP/Postal Code
Home Telephone Number
Safe Daytime Telephone
E-mail Address
Number (with area code)
(with area code)
(optional)
A-Number (if any)
U.S. Social Security Number (if any)
Gender
Female
Male
Marital Status:
Single/Never Married
Married
Divorced
Widowed
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
Passport Number
Place of Issuance
Date of Issue (mm/dd/yyyy)
Give the following information about your family member if he or she is currently in the United States.
Place of Last Entry
Date of Last Entry (mm/dd/yyyy)
I-94 Number (Arrival-Departure Document)
Current Immigration Status
Give the following information about your family member if he or she has previously traveled to the United States.
Place of Entry
Date of Entry
Date Authorized Stay
Immigration Status
(mm/dd/yyyy)
Expired (mm/dd/yyyy)
Form I-914, Supplement A 02/27/17 Y
Page 2

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