Form I-914 - Application For T Nonimmigrant Status Page 2
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10PART C. Additional Information
Answers to the following questions about your claim require explanation and supporting documentation. You should attach
documents in support of your claim that you are a victim of a severe form of trafficking in persons and the specific facts on which you
are relying to support your claim. You must attach a personal narrative statement describing the trafficking. If you are only applying
for T derivative status for a family member subsequent to your (the principal applicant) initial filing, evidence supporting the original
application is not require to be resubmitted with the new Form I-914.
Attach additional sheets of paper as needed. Write your name and Alien Registration Number (A-Number), if any, at the top of each
sheet and indicate the number of the item that you are answering. Include the Part and letter or number relating to the additional
information you provided (example: Part C, 3).
1. I am or have been a victim of a severe form of trafficking in persons. (Attach evidence to support your claim.)
Yes
No
2. I am submitting a law enforcement agency (LEA) declaration on Form I-914, Supplement B, Declaration of
Yes
No
Law Enforcement Officer for Victim of Trafficking in Persons. (If "No," explain why you are not submitting
the LEA Certification.)
3. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern
Yes
No
Mariana Islands, or at a port of entry, on account of trafficking, or have been allowed entry into the United
States to participate in investigative or judicial processes associated with an act or perpetrator of trafficking.
(If "Yes," explain in detail and attach evidence and documents supporting this claim.)
4. I fear that I will suffer extreme hardship involving unusual and severe harm upon removal. (If "Yes," explain
Yes
No
in detail and attach evidence and documents supporting this claim.)
5. I have reported the crime of which I am claiming to be a victim. (If "Yes," indicate to which law enforcement
Yes
No
agency and office you have made the report, the address and phone number of that office, and the case
number assigned, if any. If "No," explain the circumstances.)
Law Enforcement Agency and Office
Address
Phone Number
Case Number
Circumstances:
6. I am under the age of 18 years. (If "Yes," proceed to Question 8.)
Yes
No
7. I have complied with requests from Federal, State, or local law enforcement authorities for assistance in the
Yes
No
investigation or prosecution of acts of trafficking, or am unable to cooperate with such requests due to
physical or psychological trauma. (If "No," explain the circumstances.)
8. This is the first time I have entered the United States. (If "No," list each date, place of entry, and under which
Yes
No
status you entered the United States for the past five years, and explain the circumstances of your most recent
arrival.)
Date of Entry
Place of Entry
Status
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Form I-914 02/27/17 Y
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