Form I-914 - Application For T Nonimmigrant Status Page 3
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10PART C. Additional Information (continued)
9. My most recent entry was on account of the trafficking that forms the basis for my claim. (Explain the
Yes
No
circumstances of your most recent arrival.)
10. I want an Employment Authorization Document.
Yes
No
11. I am now applying for one or more eligible family members. (If "Yes," complete and include a Form I-914,
Yes
No
Supplement A, Application for Immediate Family Member of T-1 Recipient, for each family member for whom
you are now applying. You may also apply to bring eligible family members to the United States at a later
date.)
PART D. Processing Information
Answer the following questions about yourself. For purposes of this application, if applicable, you must answer “Yes” to the following
questions, even if your records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney,
told you that you no longer have a record. (If your answer is "Yes" to any one of these questions, explain on a separate sheet of paper.
Additionally, explain if any of the acts or circumstances below are related to you having been a victim of a severe form of trafficking.
Answering "Yes" does not necessarily mean that you will be denied T nonimmigrant status or are not entitled to adjust your status or
register for permanent residence.)
1. Have you EVER:
a. Committed a crime or offense for which you have not been arrested?
Yes
No
b. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military
Yes
No
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)?
f. Received a suspended sentence, been placed on probation, or been paroled?
Yes
No
g. Been in jail or prison?
Yes
No
h. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action?
Yes
No
i. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?
Yes
No
If you answered “Yes” to any of the above questions, complete the following table. If you need more space, use a separate sheet
of paper to give the same information.
Why were you arrested, cited,
Date of arrest,
Where were you arrested,
Outcome or disposition
detained, or charged?
citation, detention,
cited, detained, or
(e.g., no charges filed,
charge
charged?
charges dismissed, jail,
(mm/dd/yyyy)
(City, State, Country)
probation, etc.)
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Form I-914 02/27/17 Y
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