Form I-817 - Application For Family Unity Benefits Page 8
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1228.
Have you EVER assisted or participated in selling or
Part 4. Other Information (continued)
providing weapons to any person who to your knowledge
used them against another person, or in transporting
Previous Residence 6
weapons to any person who to your knowledge used them
24.a.
Street Number
against another person?
Yes
No
and Name
29.
Have you EVER received any type of military,
24.b.
Apt.
Ste.
Flr.
paramilitary, or weapons training?
Yes
No
24.c. City or Town
Have you EVER in the United States or Abroad:
24.d.
State
24.e. ZIP Code
30.a. Engaged in, conspired to engage in, or intended to engage
24.f.
Dates of Residence
(mm/dd/yyyy)
in a terrorist activity with intent to cause death or serious
bodily harm?
From
To
Yes
No
30.b. Been a representative of a terrorist organization or a
NOTE: If you need more space to complete an answer in Item
member of an organization which you knew or should have
Numbers 5.a. - 24.f., use Part 9. Additional Information.
known is a terrorist organization?
Yes
No
Answer Item Numbers 25.a. - 38. If you answer “Yes” to
Have you EVER engaged in any activity to violate any
31.
ANY of the questions, use the space provided in Part 9.
law of the United States related to espionage or sabotage
Additional Information to provide an explanation.
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
Have you EVER ordered, incited, called for, committed,
information?
assisted, helped with, or otherwise participated in any of the
Yes
No
following:
Have you EVER:
25.a. Acts involving torture or genocide?
Yes
No
32.a. Been convicted by a final judgment of a particularly
25.b. Killing any person?
Yes
No
serious crime?
Yes
No
25.c. Intentionally and severely injuring any person?
32.b. Participated in any other criminal activity which
Yes
No
endangers public safety or national security of the
United States?
Yes
No
25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Have you EVER been convicted of any offenses for
33.
Yes
No
which the aggregate sentences were five or more years
of confinement?
Yes
No
25.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
Have you EVER been ordered deported, excluded, or
34.
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
Have you EVER:
status?
Yes
No
26.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
Have you EVER been convicted of a felony crime of
35.
defense unit, vigilante unit, rebel group, guerilla group,
violence that has an element of or attempted use of
militia, or insurgent organization?
Yes
No
physical force against another individual in the course of
committing the offense?
Yes
No
26.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
Have you EVER engaged in genocide, or ordered, incited,
36.
persons?
Yes
No
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
27.
Have you EVER been a member of, assisted in, or
membership in a particular social group, or political
participated in any group, unit or organization of any kind
opinion?
Yes
No
in which you or other persons used any type of weapon
against any person or threatened to do so?
Yes
No
Form I-817 12/23/16 N
Page 8 of 12
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