Form I-918 - Petition For U Nonimmigrant Status Page 2
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11If you need extra space to complete Part 2., use the space
Part 1. Information About You (continued)
provided in Part 8. Additional Information.
9.
Gender
Male
Female
Select "Yes" or "No," as appropriate, for each of the following
questions.
10.
Date of Birth (mm/dd/yyyy)
1.
I am a victim of criminal activity listed in the INA at
11.
Country of Birth
section 101(a)(15)(U)(iii).
Yes
No
2.
I have suffered substantial physical or mental abuse as a
12.
Country of Citizenship or Nationality
result of having been a victim of this criminal activity.
Yes
No
13.
Form I-94 Arrival-Departure Record Number
3.
I possess information concerning the criminal activity of
which I was a victim.
►
Yes
No
4.
I am submitting Form I-918, Supplement B, U
14.
Passport Number
Nonimmigrant Status Certification, from a certifying
official.
15.
Travel Document Number
Yes
No
16.
Country of Issuance for Passport or Travel Document
5.
The crime of which I am a victim occurred in the United
States (including Indian country and military installations)
or violated the laws of the United States.
17.
Date of Issuance for Passport or Travel Document
Yes
No
(mm/dd/yyyy)
6.
I am under 16 years of age.
Yes
No
18.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
7.a.
I was or am in immigration proceedings.
Yes
No
Place and Date of Last Entry into the United States and Date
Authorized Stay Expired
If you answered "Yes," select the type of proceedings. If you
were in proceedings in the past and are no longer in proceedings,
19.a.
City or Town
provide the date of action. If you are currently in proceedings,
type or print “Current” in the appropriate date field. Select all
19.b.
State
applicable boxes. Use the space provided in Part 8. Additional
Information to provide an explanation.
Date of Last Entry into the United States
20.
(mm/dd/yyyy)
Removal Proceedings
7.b.
Removal Date (mm/dd/yyyy)
21.
Date Authorized Stay Expired (mm/dd/yyyy)
7.c.
Exclusion Proceedings
Exclusion Date (mm/dd/yyyy)
22.
Current Immigration Status
7.d.
Deportation Proceedings
Deportation Date (mm/dd/yyyy)
7.e.
Rescission Proceedings
Part 2. Additional Information About You
Rescission Date (mm/dd/yyyy)
Answering “Yes” to the following questions below requires
explanations and supporting documentation. Attach relevant
7.f.
Judicial Proceedings
documents in support of your claims that you are a victim of
Judicial Date (mm/dd/yyyy)
criminal activity listed in the Immigration and Nationality Act
(INA) section 101(a)(15)(U)(iii). You must also attach a
personal narrative statement describing the criminal activity of
which you are a victim. If you are only petitioning for U
derivative status for qualifying family members subsequent to
your (the principal petitioner) initial filing, you are not required
to submit evidence supporting the original petition with the new
Form I-918.
Page 2 of 11
Form I-918 02/07/17 N
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