Form I 914 Supplement A – Fill Out and Use This PDF

Form I 914 Supplement A is a necessary part of employment eligibility verification. It provides the information needed to validate an employee's identification documents. By filling out this form, employers can ensure the applicants they are bringing on board follow compliance with criteria set by the U.S. Department of Homeland Security and Immigration work Authorization Rules. This documentation proves that United States citizens or nationals are legally allowed to accept employment or jobs in this country. Completion of Form I 914 Supplement A mitigates any potential liabilities that arise from a misclassification of an individual based on their citizenship status.

Form I 914 Supplement A PDF Details

The U.S. Citizenship and Immigration Services (USCIS) released a new form, Form I 914 Supplement A, on November 14, 2016. This form is used to request an extension of stay for victims of human trafficking. The form must be filed before the victim's current status expires. There are several important things to keep in mind when filing this form: -The victim must still meet the definition of a trafficking victim under U visas and T visas. -The extension should not be used to allow the victim to work in the United States; that is what Form I 797 is for. -The USCIS may ask for additional information or documentation to support the request for an extension. It is important to file this form correctly and submit all necessary supporting documents so that the USCIS can make a decision on the extension request promptly.

Question	Answer
Form Name	Form I 914 Supplement A
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	Reloc, DHS, trafficked, USCIS

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OMB No. 1615-0099; Expires 05/31/2014

Department of Homeland Security

U.S. Citizenship and Immigration Services

I-914, Supplement A, Application for Immediate Family Member of T-1 Recipient

START HERE - Type or print. Use black ink. 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. His or her family member(s) is referred to as a derivative applicant. Form I-914, Supplement A, is to be

completed by the principal applicant.

PART A. Family Member Relationship to You (the principal)

The family member that I am filing for is my: (Check one)

Husband/Wife

Child

Parent

Unmarried Sibling Under Age 18

PART B. General Information About You (the principal)

Family Name (Last Name)		Given Name (First Name) Middle Name (if any)

Date of Birth (mm/dd/yyyy)		A # (if any)

Status of your Form I-914, Application for T Nonimmigrant Status: (Check one)

Filing this Form I-914, Supplement A, concurrently

Pending

Approved

PART C. Information About Your Family Member (the derivative)

Family Name (Last Name)

Given Name (First Name)

Middle Name (if any)

Other Names Used (include maiden name/nickname)

Date of Birth (mm/dd/yyyy)

Country of Birth

Country of Citizenship

Residence or Intended Residence in the U.S. - Street Number and Name

Apt. #

City

State

Zip Code

Safe Mailing Address (if other than above) - Street Number and Name

Apt. #

C/O (in care of):

For USCIS Use Only

Returned

Receipt

Date

Resubmitted

Date

Reloc Sent

Date

Reloc Rec'd

Date

Validity Dates

From:

To:

Remarks

Conditional Approval

Stamp #

Date

Action Block

City

Home Telephone # (with area code)

A # (if any)

Marital Status:

Married

		State/Province		Zip/Postal Code

Safe Daytime Phone #			I-94 # (Arrival-Departure
(with area code)			Document)


	U.S. Social Security # (if any) Gender
				Male	Female
				Male	Female

Single/Never Married			Divorced		Widowed

To Be Completed by

Attorney or Representative, if any

Fill in box if G-28 is attached to represent the applicant.

ATTY State License #

Form I-914, Supplement A (Rev. 05/04/12) Y

PART C. Information About Your Family Member

(Continued)

1.Give the following information about your family member if he or she is currently in the United States.

Place of Last Entry		Date of Last Entry (mm/dd/yyyy)	Current Immigration Status


Passport #	Place of Issuance			Date of Issue (mm/dd/yyyy)

2.Give the following information about your family member if he or she has previously traveled to the United States.

Place of Entry

Date of Entry

(mm/dd/yyyy)

Date Authorized Stay

Expired (mm/dd/yyyy)

Immigration Status

3.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.

Name of Former Spouse(s)

Date Marriage Ended

(mm/dd/yyyy)

Where and How Marriage Ended

4.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.

Type of Office (Check one):

Office Address (City)

Consulate

Pre-Flight Inspection

Port of Entry

U.S. State or Foreign Country

Foreign Address Where You Want Notification Sent

5.Has your family member ever been in immigration proceedings?

If "Yes," what type of proceedings? (Check all that apply)

Removal Date	Exclusion Date	Deportation Date
(mm/dd/yyyy)	(mm/dd/yyyy)	(mm/dd/yyyy)

Rescission Date (mm/dd/yyyy)

Yes

Judicial Date (mm/dd/yyyy)

Form I-914, Supplement A (Rev. 05/04/12) Y Page 2

PART C. Information About Your Family Member

(Continued)

6.Is your family member requesting an Employment Authorization Document? (If "Yes," submit Form I-765, Application for Employment Authorization Document, separately.)

Yes

NOTE: 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 D. Processing Information

Answer the following questions about your family member. For the purposes of this application, if applicable, you must answer “Yes” 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.)

1.Has the family member for whom you are filing EVER:

a.Committed a crime or offense for which he or she has not been arrested?

b.Been arrested, cited, or detained by any law enforcement officer (including DHS, former INS, and military officers) for any reason?

c.Been charged with committing any crime or offense?

d.Been convicted of a crime or offense (even if violation was subsequently expunged or pardoned)?

e.Been placed in an alternative sentencing or a rehabilitative program (for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)?

f.Received a suspended sentence, been placed on probation, or been paroled?

g.Been in jail or prison?

h.Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action?

i.Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?

Yes

If the answer is “Yes” 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	Date of arrest,	Where was the family member	Outcome or disposition
you are filing arrested, cited, detained,	citation,	for whom you are filing arrested,	(e.g., no charges filed,
or charged?	detention, charge	cited, detained, or charged?	charges dismissed, jail,
	(mm/dd/yyyy)	(City, State, Country)	probation, etc.)

Form I-914, Supplement A (Rev. 05/04/12) Y Page 3

PART D. Processing Information

(Continued)

2. Has the family member for whom you are filing EVER received public assistance in the United States from any		Yes	No
		Yes	No
source, including the U.S. Government or any State, county, city or other municipality (other than emergency
medical treatment), or is he or she likely to receive public assistance in the future?

3. 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	Yes	No
	procurement of prostitution?
	b. EVER engaged in any unlawful commercialized vice, including but not limited to illegal gambling?	Yes	No
	c. EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States	Yes	No
	illegally?
	d. EVER illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the	Yes	No
	illicit trafficking of any controlled substance?

4.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)?

b.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?

c.Assassination?

d.The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property?

e.The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more individuals or to cause substantial damage to property?

Yes

5.Has the family member for whom you are filing EVER been a member of, solicited money or members for, provided support for, attended military training (as defined in section 2339D(c)(1) of title 18, United States Code) by or on behalf of, or been associated with an organization that is:

a.Designated as a terrorist organization under section 219 of the Immigration and Nationality Act?

b.Any other group of two or more individuals, whether organized or not, which has engaged in or has a subgroup which has engaged in:

1.Hijacking or sabotage of any conveyance (including an aircraft, vessel, or vehicle)?

2.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

3.Assassination?

4.The use of any firearm with intent to endanger, directly or indirectly, the safety of one or more individual or to cause substantial damage to property?

Yes

Form I-914, Supplement A (Rev. 05/04/12) Y Page 4

PART D. Processing Information

(Continued)

5.		Soliciting money or members or otherwise providing material support to a terrorist organization?	Yes	No
6.		The use of any biological agent; chemical agent; or nuclear weapon or device; explosive; or other	Yes	No
		weapon or dangerous device, with intent to endanger, directly or indirectly, the safety of one or more
		individuals or to cause substantial damage to property?

6. Does the family member for whom you are filing intend to engage in the United States in:
	a. Espionage?		Yes	No
	b. Any unlawful activity, or any activity the purpose of which is in opposition, to control or overthrow of the		Yes	No
	Government of the United States?
	c. Solely, principally, or incidentally in any activity related to espionage or sabotage or to violate any law		Yes	No
	involving the export of goods, technology, or sensitive information?

7.Has the family member for whom you are filing EVER been or does he or she continue to be a member of the Communist or other totalitarian party, except when membership was involuntary?

Yes

8. Has the family member for whom you are filing, during the period of March 23, 1933, to May 8, 1945, in

Yes

association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race, religion, nationality, membership in a particular social group, or political opinion?

9.Has the family member for whom you are filing EVER been present or nearby when any person was:

a.	Intentionally killed, tortured, beaten, or injured?	Yes	No
b.	Displaced or moved from his or her residence by force, compulsion, or duress?	Yes	No
c.	In any way compelled or forced to engage in any kind of sexual contact or relations?	Yes	No

10.a. Are removal, exclusion, rescission, or deportation proceedings pending against the family member for whom your are filing?

b.Have removal, exclusion, rescission, or deportation proceedings EVER been initiated against the family member for whom your are filing?

c.Has the family member for whom your are filing EVER been removed, excluded, or deported from the United States?

d.Has the family member for whom your are filing EVER been ordered to be removed, excluded, or deported from the United States?

e.Has the family member for whom your are filing EVER been denied a visa or denied admission to the United States? (If a visa was denied, explain why on a separate sheet of paper.)

f.Has the family member for whom your are filing EVER been granted voluntary departure by an immigration officer or an immigration judge and failed to depart within the allotted time?

Yes

Form I-914, Supplement A (Rev. 05/04/12) Y Page 5

PART D. Processing Information

(Continued)

11.Has the family member for whom you are filing (or has any member of his or her family) EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:

a.Acts involving torture or genocide?

b.Killing any person?

c.Intentionally and severely injuring any person?

d.Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?

e.Limiting or denying any person's ability to exercise religious beliefs?

Yes

12.Has the family member for whom you are filing EVER:

a.Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization?

b.Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?

Yes

13.Has the family member for whom you are filing EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which he or she or any other persons used any type of weapon against any person or threatened to do so?

Yes

14.Has the family member for whom you are filing EVER assisted or participated in selling or providing weapons to any person who to his or her knowledge used them against another person, or in transporting weapons to any person who to his or her knowledge used them against another person?

Yes

15.Has the family member for whom you are filing EVER received any type of military, paramilitary, or weapons training?

Yes

16.Is the family member for whom you are filing under a final order or civil penalty for violating section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)?

Yes

17.Has the family member for whom you are filing EVER, by fraud or willful misrepresentation of a material fact, sought to procure, or procured, a visa or other documentation, for entry into the United States or any immigration benefit?

Yes

18.Has the family member for whom you are filing EVER left the United States to avoid being drafted into the U.S. Armed Forces?

Yes

19.Has the family member for whom you are filing EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement and not yet complied with that requirement or obtained a waiver of such?

Yes

20.Has the family member for whom you are filing EVER detained, retained, or withheld the custody of a child, having a lawful claim to U.S. citizenship, outside the United States from a U.S. citizen granted custody?

Yes

Form I-914, Supplement A (Rev. 05/04/12) Y Page 6

PART D. Processing Information

(Continued)

21.Does the family member for whom you are filing plan to practice polygamy in the United States?

Yes

22.Did the family member for whom you are filing enter the United States as a stowaway?

Yes

23.a. Does the family member for whom you are filing have a communicable disease of public health significance?

b.Does the family member for whom you are filing have or has he or she had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of themselves or others?

Yes

c.Is the family member for whom you are filing now or has he or she been a drug abuser or drug addict?

Yes

PART E. Attestation, Release, and Signature

After reading the information regarding penalties in the instructions, you, the principal, must sign below. Your family member for whom you are applying must also sign below if he or she is presently in the United States. If someone helped you prepare this supplementary application, he or she must complete Part F.

I have read, or had read to me, this form, the information provided on it, and the evidence provided with it.

I authorize the release of any information from my record that U.S. Citizenship and Immigration Services (USCIS) needs to determine eligibility for the benefit I am seeking for the family member for whom I am applying, to investigate my claim, and to investigate fraudulent claims. I further authorize USCIS to release information to law enforcement agencies and prosecutors investigating or prosecuting crimes of trafficking or related crimes. I further authorize USCIS to release information to Federal, State, and local public and private agencies providing benefits, to be used solely in making determinations of eligibility for benefits pursuant to 8 USC 1641(c).

Principal Applicant's Statement and Signature (Choose one of the following):

I can read and understand English, and I have read and understand each and every question and instruction on this form, as well as my answer to each question.

Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the language, a language in which I am fluent, by the person named in Interpreter's Statement and

Signature. I understand each and every question and instruction on this form, as well as my answer to each question.

Principal Applicant's Signature (you)		Date (mm/dd/yyyy)

Signature of Derivative (your family member if physically present in the United States)

Date (mm/dd/yyyy)

Form I-914, Supplement A (Rev. 05/04/12) Y Page 7

PART F. Preparer and/or Interpreter Certification and Signature

To be completed and signed if form is prepared by a person other than the applicant.

Preparer's Statement and Signature (if applicable)

I declare that I prepared this application at the request of the above person, and it is based on all information of which I have knowledge. I have not knowingly withheld any material information that would affect the outcome of this application.

Attorney or Representative: In the event of a Request for Evidence, may USCIS contact you by fax or e-mail?		Yes
Preparer's Signature	Date (mm/dd/yyyy)

Preparer's Printed Name		Preparer's Firm Name (if applicable)

Preparer's Address

Daytime Phone Number (with area code) Fax Number (if any)

E-Mail Address (if any)

Interpreter's Statement and Signature (if applicable)

I certify that I am fluent in English and the below-mentioned language.

Language used (language in which applicant is fluent):

I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as well as the answer to each question.

Interpreter's Signature		Date (mm/dd/yyyy)

Printed Name	Telephone Number (with area code)

WARNING: Applicants who are in the United States illegally are subject to removal if their claims are not granted. Any information provided in completing this application may be used as a basis for the institution of, or as evidence in, removal proceedings even if the application is later withdrawn.

Form I-914, Supplement A (Rev. 05/04/12) Y Page 8

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2. Soon after the last section is filled out, go to enter the applicable details in these: City, State, Zip Code, Stamp, Date, Safe Mailing Address if other than, Apt, Action Block, CO in care of, City, StateProvince, ZipPostal Code, Home Telephone with area code, Safe Daytime Phone with area code, and I ArrivalDeparture Document.

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3. This next step is normally hassle-free - complete all of the fields in Place of Last Entry, Date of Last Entry mmddyyyy, Current Immigration Status, Passport, Place of Issuance, Date of Issue mmddyyyy, Give the following information, Place of Entry, Date of Entry mmddyyyy, Date Authorized Stay Expired, Immigration Status, If your family member was, and as divorce decrees or death to complete this part.

4. The following section requires your information in the following places: Date Marriage Ended mmddyyyy, If your family member is outside, application is approved, Type of Office Check one, Consulate, PreFlight Inspection, Port of Entry, Office Address City, US State or Foreign Country, Foreign Address Where You Want, Has your family member ever been, Yes, If Yes what type of proceedings, Removal Date mmddyyyy, and Exclusion Date mmddyyyy. Make sure that you provide all requested info to go forward.

rehabilitative writing process described (part 4)

5. This last section to finish this PDF form is crucial. Ensure that you fill out the appropriate blanks, which includes PART C Information About Your, Is your family member requesting, Yes, Application for Employment, NOTE If your family member is, PART D Processing Information, Answer the following questions, Has the family member for whom, a Committed a crime or offense for, b Been arrested cited or detained, officers for any reason, c Been charged with committing any, d Been convicted of a crime or, e Been placed in an alternative, and prosecution withheld adjudication, before finalizing. Otherwise, it may lead to an unfinished and possibly incorrect document!

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Form I 914 Supplement A – Fill Out and Use This PDF

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