Form I-918 - Supplement A - Petition For Qualifying Family Member Of U-1 Recipient
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12Supplement A, Petition for Qualifying Family Member
USCIS
of U-1 Recipient
Form I-918
Department of Homeland Security
OMB No. 1615-0104
U.S. Citizenship and Immigration Services
Expires 02/28/2019
Action Block
Receipt
Remarks
For
USCIS
Use
Only
Validity Dates (mm/dd/yyyy)
Wait Listed
U.S.
From:
Embassy
/
/
/
Consulate
To:
/
/
/
Stamp Number
Date (mm/dd/yyyy)
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
To be completed by an
(if applicable)
USCIS Online Account Number (if any)
Form G-28 is
attorney or accredited
attached.
representative (if any).
►
START HERE - Type or print in black or blue ink.
NOTE: The recipient of the U-1 nonimmigrant classification is referred to as the "principal." His or her family members are referred
to as "derivatives." The principal should complete Supplement A.
Part 1. Family Member's Relationship To You
Part 3. Information About Your Qualifying
Family Member (Derivative)
(Principal)
1.a. Family Name
1.
The family member that I am filing for is my:
(Last Name)
Spouse
Parent
Child
1.b. Given Name
Unmarried sibling under 18 years of age
(First Name)
1.c. Middle Name
Part 2. Information About You (Principal)
Other Names Used (Include maiden name, nicknames, and
1.a. Family Name
aliases, if applicable)
(Last Name)
2.a. Family Name
1.b. Given Name
(Last Name)
(First Name)
2.b. Given Name
1.c. Middle Name
(First Name)
2.c. Middle Name
Other Information
NOTE: If you need extra space to complete this section, use the
space provided in Part 11. Additional Information.
2.
Date of Birth (mm/dd/yyyy)
3.
Residence or Intended Residence in the United
Alien Registration Number (A-Number) (if any)
States
A-
►
3.a. Street Number
4.
USCIS Online Account Number (if any)
and Name
►
3.b.
Apt.
Ste.
Flr.
5.
Status of your Form I-918
3.c. City or Town
Pending
Approved
3.d. State
3.e. ZIP Code
Page 1 of 12
Form I-918 Supplement A 02/07/17 N
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