Page 1Form I-914 04/15/19 Application for T Nonimmigrant Status Department of Homeland Security U.S. Citizenship and Immigration Services Conditional Approval For USCIS Use Only Remarks Action Block Returned Date Resubmitted Reloc Sent Reloc Rec'd Receipt To Be Completed by Attorney or Representative, if any Validity Dates From: To:Stamp #Date DateCheck all that apply: START HERE - Type or print.240 Use black ink.240 See Instructions for information about eligibility and how to complete and file this application. PART A.240240 Purpose for Filing the Application Date of Birth (mm/dd/yyyy) Middle Name (if any) Given Name (First Name) Family Name (Last Name) Other Names Used (Include maiden name/nickname) Home Address - Street Number and Name Apt. Number City State/Province Zip/Postal Code C/O (in care of): Safe Mailing Address (if other than above) -240Street Number and Name Apt. Number City State/Province Zip/Postal Code Country of Citizenship Country of Birth Passport Number Place of Issuance Home Telephone Number (with area code) Safe Daytime Phone Number (with area code) E-Mail Address (optional) PART B.240 General Information About You (Person filing this form as a victim)Gender A-Number (if any) U.S. Social Security Number (if any)Marital Status: Date of Issue (mm/dd/yyyy) Place of Last Entry Date of Last Entry (mm/dd/yyyy) Male Female Married Divorced Widowed Single/Never Married Fill in box if G-28 is attached to represent the applicant. ATTY State License # Date Date Date Date Date DateUSCIS Form I-914 OMB No. 1615-0099 Expires 04/30/2021 Receipt Number (begins with EAC)I am filing for T-1 nonimmigrant status and have not previously filed for such status.I am filing for T-1 nonimmigrant status and have previously filed for such status. I have received T-1 status and am applying to bring family members to the United States. Form I-94 Number (Arrival-Departure Record) Current Immigration Status (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Page 2Form I-914 04/15/19 Answers to the following questions about your claim require explanation and supporting documentation. You should attach documents in support of your claim that you are a victim of a severe form of trafficking in persons and the specific facts on which you are relying to support your claim. You must attach a personal narrative statement describing the trafficking. If you are only applying for T derivative status for a family member subsequent to your (the principal applicant) initial filing, evidence supporting the original application is not require to be resubmitted with the new Form I-914. Attach additional sheets of paper as needed. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet and indicate the number of the item that you are answering. Include the Part and letter or number relating to the additional information you provided (example: Part C, 3). PART C.240240 Additional Information Yes No Yes No1. I am or have been a victim of a severe form of trafficking in persons. (Attach evidence to support your claim.)2. I am submitting a law enforcement agency (LEA) declaration on Form I-914, Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons. (If "No," explain why you are not submitting the LEA Certification.) Yes No3. I am physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana Islands, or at a port of entry, on account of trafficking, or have been allowed entry into the United States to participate in investigative or judicial processes associated with an act or perpetrator of trafficking. (If "Yes," explain in detail and attach evidence and documents supporting this claim.) Yes No4. I fear that I will suffer extreme hardship involving unusual and severe harm upon removal. (If "Yes," explain in detail and attach evidence and documents supporting this claim.) Yes No5. I have reported the crime of which I am claiming to be a victim. (If "Yes," indicate to which law enforcement agency and office you have made the report, the address and phone number of that office, and the case number assigned, if any.240 If "No," explain the circumstances.) Law Enforcement Agency and Office Address Phone Number Case Number Circumstances: Yes No7. I have complied with requests from Federal, State, or local law enforcement authorities for assistance in the investigation or prosecution of acts of trafficking, or am unable to cooperate with such requests due to physical or psychological trauma. (If "No," explain the circumstances.)6. I am under the age of 18 years. (If "Yes," proceed to Question 8.) Yes No8. This is the first time I have entered the United States. (If "No," list each date, place of entry, and under which status you entered the United States for the past five years, and explain the circumstances of your most recent arrival.) Yes No Date of Entry Place of Entry Status American LegalNet, Inc. www.FormsWorkFlow.com Page 3Form I-914 04/15/19 PART C.240240 Additional Information (continued) Yes No 9. My most recent entry was on account of the trafficking that forms the basis for my claim. (Explain the circumstances of your most recent arrival.) Yes No10. I want an Employment Authorization Document. Yes No11. I am now applying for one or more eligible family members. (If "Yes," complete and include a Form I-914, 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.240240 Processing Information1. Have you EVER: Yes Noa. Committed a crime or offense for which you have not been arrested? Yes Nob. Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military officers) for any reason? Yes Noc. Been charged with committing any crime or offense? Yes Nod. Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)? Yes Noe. Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes Nof. Received a suspended sentence, been placed on probation, or been paroled? Yes Nog. Been in jail or prison? Yes Noh. Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action? Yes Noi. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?Answer the following questions about yourself. For purposes of this application, if applicable, you must answer 223Yes224 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.)If you answered 223Yes224 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, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where were you arrested, cited, detained, or charged? (City, State, Country) Outcome or disposition (e.g., no charges filed, charges dismissed, jail, probation, etc.) American LegalNet, Inc. www.FormsWorkFlow.com Page 4Form I-914 04/15/19 2. Have you: PART D.240240 Processing Information (continued)a. Engaged in prostitution or procurement of prostitution or do you intend to engage in prostitution or procurement of prostitution? Yes No Yes Nob. EVER engaged in any unlawful commercialized vice, including, but not limited to illegal gambling? Yes Noc. EVER knowingly encouraged, induced, assisted, abetted, or aided any ali