Form I-918 - Supplement A - Petition For Qualifying Family Member Of U-1 Recipient Page 2
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1217.
Date of Issuance for Passport or Travel Document
Part 3. Information About Your Qualifying
(mm/dd/yyyy)
Family Member (The Derivative) (continued)
Expiration Date for Passport or Travel Document
Safe Mailing Address (if other than Residence)
18.
(mm/dd/yyyy)
4.a.
In Care Of Name
Part 4. Additional Information About Your
4.b.
Street Number
Qualifying Family Member
and Name
Provide the date of last entry, place of last entry, and current
4.c.
Apt.
Ste.
Flr.
immigration status for your family member if he or she is
currently in the United States.
4.d. City or Town
1.a. Date of Last Entry into the United States (mm/dd/yyyy)
4.e. State
4.f.
ZIP Code
4.g.
Province
Place of Last Entry into the United States
4.h.
Postal Code
1.b.
City or Town
4.i.
Country
1.c.
State
1.d.
Current Immigration Status
Other Information About Qualifying Family
Member
Provide the date of entry, place of entry, and status at entry
for your family member's last entry if he or she has
A-
5.
A-Number (if any) ►
previously traveled to the United States but is not currently
in the United States.
U.S. Social Security Number (if any)
6.
►
2.a. Date of Last Entry into the United States (mm/dd/yyyy)
USCIS Online Account Number (if any)
7.
►
Place of Last Entry into the United States
8.
Date of Birth (mm/dd/yyyy)
2.b.
City or Town
9.
Country of Birth
2.c.
State
2.d. Date Authorized Stay Expired (mm/dd/yyyy)
10.
Country of Citizenship or Nationality
2.e.
Status at the Time of Entry (for example, F-1 student,
11.
Marital Status
B-2 tourist, entered without inspection)
Single
Married
Divorced
Widowed
12.
Gender
Male
Female
Form I-94 Arrival-Departure Record Number
13.
►
14.
Passport Number
15.
Travel Document Number
16.
Country of Issuance for Passport or Travel Document
Page 2 of 12
Form I-918 Supplement A 02/07/17 N
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