Page 1 Form I-914, Supplement A 04/15/19 Supplement A, Application for Family Member of T-1 Recipient Department of Homeland Security U.S. Citizenship and Immigration Services Receipt Middle Name (if any) Given Name (First Name) Family Name (Last Name) Other Names Used (include maiden name/nickname) PART D.240 Information About Your Family Member (the derivative) PART A.240 Family Member Relationship to You (the principal)START HERE - Type or print.240Use black ink.240 See Instructions for information about eligibility and how to complete and file this application. The recipient of the T nonimmigrant classification is referred to as the principal applicant. 240His or her family member(s) is referred to as a derivative applicant.240 Form I-914, Supplement A, is to be completed by the principal applicant.The family member that I am filing for is my: (Check one) Husband/Wife Child Parent Unmarried Sibling Under 18 Years of Age Conditional Approval For USCIS Use Only Remarks Action Block Returned Date Resubmitted Reloc Sent Reloc Rec'd Validity Dates From: To:Stamp #Date Date 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 PART B. Family Member Relationship to Your DerivativeThe family member I am filing for is the adult or minor child of my derivative (my grandchild, my spouse's child, my niece or nephew, or my sibling) who faces a present danger of retaliation as a result of my escape from the severe form of trafficking in persons or my cooperation with law enforcement. PART C.240 General Information About You (the principal)Status of your Form I-914, Application for T Nonimmigrant Status: (Check one) Pending Filing this Form I-914, Supplement A, concurrently Approved Middle Name (if any) Given Name (First Name) Family Name (Last Name) A-Number (if any) Date of Birth (mm/dd/yyyy) Derivative's Adult Minor ChildOR Residence or Intended Residence in the U.S. - Street Number and Name Apt. Number City State ZIP Code To Be Completed by Attorney or Representative, if any(USPS ZIP Code Lookup ) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Form I-914, Supplement A 04/15/19 PART D.240 Information About Your Family Member (the derivative) (continued) Home Telephone Number (with area code) Safe Daytime Telephone Number (with area code)Gender A-Number (if any) U.S. Social Security Number (if any) Male FemaleMarital Status: Married Divorced Widowed Single/Never Married C/O (in care of): Safe Mailing Address (if other than above) -240Street Number and Name Apt. Number City State/Province E-mail Address (optional) ZIP/Postal Code Country of Citizenship Country of Birth Date of Birth (mm/dd/yyyy) Place of Issuance Date of Issue (mm/dd/yyyy)Give the following information about your family member if he or she is currently in the United States. Give the following information about your family member if he or she has previously traveled to the United States. Date of Last Entry (mm/dd/yyyy) Place of Last Entry Current Immigration Status Place of Entry Date of Entry (mm/dd/yyyy) Date Authorized Stay Expired (mm/dd/yyyy) Immigration Status Passport Number I-94 Number (Arrival-Departure Document) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 Form I-914, Supplement A 04/15/19 Name of Former Spouse(s) Date Marriage Ended (mm/dd/yyyy) Where and How Marriage Ended Type of Office (Check one): Pre-Flight Inspection Consulate Port of Entry U.S. State or Foreign Country Office Address (City) Foreign Address Where You Want Notification Sent PART D.240 Information About Your Family Member (the derivative) (continued)If your family member was previously married, list names of prior spouses and dates of termination of marriage. Documents such as divorce decrees or death certificates must be attached.If your family member is outside the United States, indicate the U.S. Consulate or inspection facility you want notified if this application is approved.Has your family member ever been in immigration proceedings?Is your family member requesting an Employment Authorization Document? (If "Yes," submit Form I-765, Application for Employment Authorization Document with Form I-914, Supplement A, or separately.) No YesIf "Yes," what type of proceedings?240 (Check all that apply) Judicial Date (mm/dd/yyyy) Removal Date (mm/dd/yyyy) Rescission Date (mm/dd/yyyy) Deportation Date (mm/dd/yyyy) Exclusion Date (mm/dd/yyyy) Yes NoNOTE: 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. Do not file Form I-765 for a family member living outside the United States. PART E.240 Processing InformationAnswer the following questions about your family member. For the purposes of this application, if applicable, you must answer 223Yes224 to the following questions even if the records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that your family member no longer has a record. (If your answer is "Yes" to any one of these questions, explain on a separate sheet of paper. Answering "Yes" does not necessarily mean that your family member will be denied T nonimmigrant status.) Yes1. Has the family member for whom you are filing EVER: Noa. Committed a crime or offense for which he or she has 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)? American LegalNet, Inc. www.FormsWorkFlow.com Page 4 Form I-914, Supplement A 04/15/19 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? PART E.240 Processing Information (continued)If the answer is 223Yes224 to any of the above questions, complete the following table. If you need more space, use a separate sheet of paper. Why was the family member for whom you are filing arrested, cited, detained, or charged? Date of arrest, citation, detention, charge (mm/dd/yyyy) Where was the family member for whom you are filing arrested, cited, detained, or charged? (City, State, Country) Outcome or disposition (e.g., no charges filed, charges dismissed, jail, probation, etc.) c. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally?2. Has the family member for whom you are filing:a. Engaged in prostitution or procurement of prostitution or does he or she 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 No Yes Nod. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? 3. Has the family member for whom you are filing EVER committed, planned or prepared, participated in, threatened to, attempted to, or conspired to commit, gathered information for, or solicited funds for any of the following:a. Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)? Yes Nob. Seizing or detaining, and threatening to kill, injure, or continue to detain, another individual in order to compel a third person (including a governmental organization) to do or abstain from doing any act as an explicit or implicit condition for the release of the individual seized or detained? Yes Noc. Assassination? Yes Nod. The use of any firearm with intent to endanger,