Form I-918 Supplement A 04/24/19 Page 1 of 12 To be completed by an attorney or accredited representative (if any). For USCIS Use Only Action BlockReceipt U.S. Embassy Consulate Validity Dates (mm/dd/yyyy) To: / / / From: / / /Wait Listed Stamp Number Date (mm/dd/yyyy)Remarks Select this box if Form G-28 is attached.Attorney State Bar Number (if applicable)Attorney or Accredited Representative USCIS Online Account Number (if any)USCIS Form I-918 OMB No. 1615-0104 Expires 04/30/2021 Supplement A, Petition for Qualifying Family Member of U-1 Recipient Department of Homeland Security U.S. Citizenship and Immigration ServicesSTART HERE - Type or print in black or blue ink. Part 1.240 Family Member's Relationship To You (Principal) Part 2. Information About You (Principal)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. Child SpouseUnmarried sibling under 18 years of age The family member that I am filing for is my:Status of your Form I-918Parent 1.1.a.Family Name (Last Name) 1.b.Given Name (First Name) 1.c.Middle Name3.5.A-2. Approved Pending Part 3. Information About Your Qualifying Family Member (Derivative)1.a.Family Name (Last Name) 1.b.Given Name (First Name) 1.c.Middle NameOther Names Used (Include maiden name, nicknames, and aliases, if applicable)Alien Registration Number (A-Number) (if any)Date of Birth (mm/dd/yyyy) Other Information2.a.Family Name (Last Name) 2.b.Given Name (First Name) 2.c.Middle NameUSCIS Online Account Number (if any)4.NOTE: If you need extra space to complete this section, use the space provided in Part 11. Additional Information. Residence or Intended Residence in the United States3.a.Street Number and Name3.c.City or Town3.d.State3.e. ZIP Code 3.b. Flr. Ste. Apt. (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement A 04/24/19 Page 2 of 12 Country of Citizenship or Nationality7. Part 3. Information About Your Qualifying Family Member (The Derivative) (continued)11.Form I-94 Arrival-Departure Record Number8.9.10.Passport Number12.Travel Document Number13. 17.18. Part 4. Additional Information About Your Qualifying Family MemberProvide the date of last entry, place of last entry, and current immigration status for your family member if he or she is currently in the United States.1.b.1.c. 1.d. Place of Last Entry into the United StatesCurrent Immigration StatusState City or Town2.b.2.c.2.e. Place of Last Entry into the United StatesState City or TownProvide the date of entry, place of entry, and status at entry for your family member's last entry if he or she has previously traveled to the United States but is not currently in the United States.2.d.Date Authorized Stay Expired (mm/dd/yyyy)Status at the Time of Entry (for example, F-1 student, B-2 tourist, entered without inspection) 14.Country of Issuance for Passport or Travel Document5.Date of Birth (mm/dd/yyyy) Other Information About Qualifying Family Member6.Country of Birth Safe Mailing Address (if other than Residence)15.Date of Issuance for Passport or Travel Document (mm/dd/yyyy)Expiration Date for Passport or Travel Document (mm/dd/yyyy)16. A-Number (if any)A-U.S. Social Security Number (if any)USCIS Online Account Number (if any) Married WidowedSingle Marital StatusDivorced GenderMale Female 1.a.Date of Last Entry into the United States (mm/dd/yyyy) 2.a.Date of Last Entry into the United States (mm/dd/yyyy) Street Number and Name4.b.4.d.City or Town4.e.State4.f.ZIP Code4.c. Ste. Flr. Apt. In Care Of Name 4.a.Province 4.g.Postal Code4.h. 4.i.Country American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement A 04/24/19 Page 3 of 12 Part 4. Additional Information About Your Qualifying Family Member (continued)If your family member was previously married, list the names of your family member's prior spouses and the dates his or her marriages were terminated. You must attach documents such as divorce decrees or death certificates.5.a.Family Name (Last Name) 5.b.Given Name (First Name) 5.c.Middle NameDate Marriage Ended (mm/dd/yyyy)5.d.Safe Foreign Address Where You Want Notification Sent (if other than U.S. Consulate, Pre-Flight Inspection, or Port-of-Entry)7.a.Your family member was or is in immigration proceedings.8. Yes NoYour family member would like an Employment Authorization Document. Other InformationIf you answered "Yes," select the type of proceedings. If your family member was in proceedings in the past and is no longer in proceedings, provide the date of action. If your family member is currently in proceedings, type or print 223Current224 in the appropriate date field. Select all applicable boxes. Use the space provided in Part 11. Additional Information to provide an explanation.NOTE: If you answered "Yes," submit Form I-765, Application for Employment Authorization Document, separately. If your family member is living outside the United States, he or she is not eligible to receive employment authorization until he or she is lawfully admitted to the United States.240 Do not file Form I-765 for a family member living outside the United States.If your family member is outside the United States, provide the U.S. Consulate or inspection facility or a safe foreign mailing address you want notified if this supplement is approved. Pre-Flight Inspection U.S. ConsulateType of Office (Select only one box):Port-of-Entry 3.a.3.d.3.b.3.c.City or Town State Country6.a.Family Name (Last Name) 6.b.Given Name (First Name) 6.c.Middle Name How did the marriage end?6.f.6.e.Where did the marriage end?Date Marriage Ended (mm/dd/yyyy)6.d. 5.e.Where did the marriage end? How did the marriage end?5.f. Street Number and Name4.a.4.b. Ste. Flr. Apt.Province 4.d.Postal Code4.e. 4.f.Country City or Town4.c. 7.c.Exclusion Date (mm/dd/yyyy) Exclusion ProceedingsRemoval Date (mm/dd/yyyy) Removal Proceedings7.b. Rescission Proceedings7.e.Judicial Date (mm/dd/yyyy)7.f.Rescission Date (mm/dd/yyyy) Judicial Proceedings Deportation ProceedingsDeportation Date (mm/dd/yyyy)7.d. No Yes American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement A 04/24/19 Page 4 of 12 Part 5. Processing InformationBeen placed in an alternative sentencing or a rehabilitative program (for example, diversion, deferred prosecution, withheld adjudication, deferred adjudication)?Been arrested, cited, or detained by any law enforcement officer (including Department of Homeland Security (DHS), former Immigration and Nationalization Service (INS), and military officers) for any reason?Committed a crime or offense for which he or she has not been arrested?Been convicted of a crime or offense (even if the violation was subsequently expunged or pardoned)?Been charged with committing any crime or offense?Has your family member EVER:Received a suspended sentence, been placed on probation, or been paroled?NOTE: Answering "Yes" does not necessarily mean that U.S. Citizenship and Immigration Services (USCIS) will deny your Supplement A, Petition for Qualifying Family Member of U-1 Recipient.NOTE: If you answer 223Yes224 to ANY question in Part 5., provide an explanation in the space provided in Part 11. Additional Information.Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action?Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?Been held in jail or prison?Answer the following questions about the family member for whom you are filing this supplement. For the purposes of this supplement, you must answer "Yes" to the following questions, if applicable, even if your family member's records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told your family member that he or she no longer has a record. 1.a.1.e.1.f.1.d.1.c.1.b. Yes No Yes No Yes No Yes No Yes No Yes No1.i.1.g.1.h. Yes No Yes No Yes NoInformation About Arrests, Citations, Detentions, or Charges Outcome or disposition (for example, no charges filed, charges dismissed, jail, probation)Where was your family member a