Form I-914 - Supplement A, Application For Family Member Of T-1 Recipient - U.s. Citizenship And Immigration Services Page 8

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PART F. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
Signature of Derivative (your family member if physically present in the United States) (sign in ink)
Date (mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.
PART G. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
Interpreter's Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
Interpreter's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
5. Interpreter's Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language specified in Part F., Item B. in
Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his
or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer.
Interpreter's Signature
7.
Interpreter's Signature (sign in ink)
Date of Signature (mm/dd/yyyy)
Form I-914, Supplement A 02/27/17 Y
Page 8

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