Application for T Nonimmigrant Status

• Legal Form Number: I-914
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Page 1

Form I-914 Edition 12/02/21

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 fully completed by an attorney or

accredited representative, if any.

Validity Dates

From:

To:

Stamp #Date

Date

Select all applicable boxes.

START HERE - Type or print in ink.

Part 1. Purpose for Filing This Application

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

Part 2. General Information About You(Person filing this application as a victim)

Select this box if Form G-28 is attached.

Attorney State License Bar Number

Date

Date

Date

Date

Date

Date

USCIS

Form I-914

OMB No. 1615-0099

Expires 12/31/2023

Receipt Number 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. (Provide receipt number below.)

1. A.

B.

(1)

1. Your Full Legal Name

Other Names Used

2.

Provide any other names you have used since birth, including aliases, maiden

names, and nicknames. If you need extra space to complete this section, use the

space provided in Part 9. Additional Information.

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

Physical Address

3.

City or TownStateZIP Code

Street Number and NameApt.Flr. NumberSte.

(USPS ZIP Code Lookup)

Safe Mailing Address

4.

If you do not want U.S. Citizenship and Immigration Services (USCIS) to send

notices about this application to your home address, you may provide an alternate

safe mailing address.

City or TownStateZIP Code

In Care Of Name

Street Number and NameApt.Flr. NumberSte.

Attorney or Accredited Representative

USCIS Online Account Number

Page 2

Form I-914 Edition 12/02/21

Gender

Marital Status

Male Female

MarriedDivorcedWidowedSingle/Never Married

Part 2. General Information About You(Person filing this application as a victim) (continued)

5. Alien Registration Number (A-Number) (if any)

►A-

6. USCIS Online Account Number (if any)

►

U.S. Social Security Number (SSN) (if any)

►

7. 8.

9. Date of Birth (mm/dd/yyyy)10.

Place of Birth

11.

City or Town State or Province

Country

12. Country of Citizenship or NationalityPassport or Travel Document Number (if any)13.

14. Country That Issued Your Passport or Travel Document (if any)Issue Date for Passport or Travel Document (if any)

(mm/dd/yyyy)

15.

Expiration Date for Passport or Travel Document (if any)

(mm/dd/yyyy)

16.

Place of Your Last Entry Into the United States17.

City or TownState

Date of Your Last Entry Into the United States, On or About

(mm/dd/yyyy)

18. Form I-94 Arrival-Departure Record Number (if any)

►

19.

Your Current Nonimmigrant Status20.

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 addressing the eligibility requirements for T

nonimmigrant status as listed in the regulations, including a description of the trafficking you experienced. If you need extra space to

complete this section, use the space provided in Part 9. Additional Information.

Part 3. Additional Information About Your Application

1. Yes No

I am or have been a victim of a severe form of trafficking in persons.

(Attach evidence to support your claim.)

2. Yes No

I have cooperated with reasonable requests for assistance from law enforcement.A.

Due to my age or the trauma I have suffered, I am exempt from the requirement to cooperate with

reasonable requests for assistance from law enforcement.

B. Yes No