Form I-914 - Supplement A, Application For Family Member Of T-1 Recipient - U.s. Citizenship And Immigration Services Page 3
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9PART D. Information About Your Family Member (the derivative) (continued)
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.
Name of Former Spouse(s)
Date Marriage Ended
Where and How Marriage Ended
(mm/dd/yyyy)
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.
Type of Office (Check one):
Consulate
Pre-Flight Inspection
Port of Entry
Office Address (City)
U.S. State or Foreign Country
Foreign Address Where You Want Notification Sent
Has your family member ever been in immigration proceedings?
Yes
No
If "Yes," what type of proceedings? (Check all that apply)
Removal Date
Exclusion Date
Deportation Date
Rescission Date
Judicial Date
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Is your family member requesting an Employment Authorization Document?
Yes
No
(If "Yes," 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, he or she is not eligible to receive employment authorization until
he or she is lawfully admitted to the United States. Do not file Form I-765 for a family member living outside the United States.
PART E. Processing Information
Answer the following questions about your family member. For the purposes of this application, if applicable, 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,
explain on a separate sheet of paper. Answering "Yes" does not necessarily mean that your family member will be denied T
nonimmigrant status.)
1. Has the family member for whom you are filing EVER:
a. Committed a crime or offense for which he or she has not been arrested?
Yes
No
b. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and
Yes
No
military officers) for any reason?
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
Yes
No
prosecution, withheld adjudication, deferred adjudication)?
Form I-914, Supplement A 02/27/17 Y
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