Form I-914 - Supplement A, Application For Family Member Of T-1 Recipient - U.s. Citizenship And Immigration Services Page 7
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9PART F. 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.
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.
B.
The interpreter named in Part G. 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 H.,
,
prepared this application for me based only upon information I provided or authorized.
Applicant's Contact Information
3.
4.
Applicant's Daytime Telephone Number
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
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.
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 USC 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.
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.
Applicant's Signature
6.
Applicant's Signature (sign in ink)
Date of Signature (mm/dd/yyyy)
Form I-914, Supplement A 02/27/17 Y
Page 7
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