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
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