Form I-854 Inter-Agency Alien Witness and Informant Record

OMB No. 1615-0046; Expires 01/31/07

I-854, Inter-Agency Alien
Witness and Informant Record

Department of Homeland Security
U.S. Citizenship and Immigration Services

Part A. To be completed by Law Enforcement Agencies. (See instructions for specific information.)
Information must be Typed or Printed clearly.
1. Name of LEA/Requestor:
2. Requesting Agent:

Control Agent:

Address:

Phone No.(Including Area Code):
Fax No.(Including Area Code):

Check if applicable:
3.

Alien will be placed in danger in

U.S.

abroad

as a result of providing information, etc.

Alien poses no danger to people or property of the U.S.
If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish.
Prosecution.

Investigation.

United States Attorney involvement.

4. Type of Request(s). (Attach legal basis for request.)
S-5

S-6

Consular post at which visa will be sought:
Change of Status - If change of status is requested, current immigration status is

DRAFT

Adjustment of Status (Go to Part F after completing information in items 5, 6 and 7 below.)
Fees attached (If applicable)

Security concerns. State special instructions regarding security precautions.

NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of the
request and any bargain the requestor wishes to make or has made with the alien. Attach a complete criminal history, FBI
No. and U.S. Social Security Number.
5. Alien's Name (Last Name, First and Middle)

Other Names Used

Alien's Address (Street Number and Name)

A#

City

Marital Status

State or Province

Date of Birth
(mm/dd/yyyy)

Date of Last Entry into U.S.
(mm/dd/yyyy):

I-94 #

Zip/Postal Code

Place of Birth (City or Country)

Current Location of Alien

Citizenship/Nationality

Form G-325
attached

Occupation

Form FD-258
attached

Photos
attached

6. On a separate application, provide all information requested in item 5 above for each beneficary who seeks derivative status spouse, parents and all sons and daughters of the alien for whom an S classification is requested. (Attach additional sheets of
paper as necessary.)
Form I-854 (Rev. 09/25/06)Y

7a. The following information must be provided for each alien named in items 5 and 6 above.
Has the alien, while outside of the United States, ever committed, ordered, incited, assisted, or otherwise participated in
genocide, torture, or extrajudicial killing or participated in Nazi persecution?
Yes

No

If yes please write a detailed statement below and attach any relevant documents. (Attach additional
sheets of paper as needed.)

7b. For the above named alien, I request waiver(s) of the following grounds of inadmissibility. (Check all possible grounds and
attach all relevant documents establishing the ground(s) of inadmissibility and why you feel a waiver is appropriate for this
alien. This information must be provided for each alien named in items 5 and 6 above. Copy this check list of the grounds of
inadmissibility for each derivative.)
Communicable disease

DRAFT

Controlled substance trafficker

Immigrant visa issued outside numerical limitation

Prostitute and/or Procurer of Prostitution

Crime involving moral turpitude

Exercised diplomatic immunity to avoid prosecution

International child abduction
Multiple criminal convictions

Engaged in unlawful commercialized vice
Entrance predudicial to public
Involved in espionage, sabotage or laws relating to technology
Coming to overthrow the U.S. Government
Foreign policy exclusion
Unqualified physician
Previously removed - aggravated felony
Stowaway
Nonimmigrant without a valid passport or visa
Previously excluded and deported or removed
Alien smuggler
Physical/mental disorder (dangerous)
Drug abuser or addict
Convicted of law pertaining to controlled substances

Unlawful activity related to National Security
Terrorist activities
Communist Party member
Public charge
Lacking labor certification
Fraud/misrepresentation
Immigrant without a visa
Draft evader-was immigrant when left U.S.
Alien accompanying helpless inadmissible alien
Violator of section 274C
Ordered, incited, assisted or otherwise participated in the
commission of the acts of torture or extra judicial killing.
Engaged in conduct relating to severe violations of
religious freedoms
Weapons charges, domestic violence, and money
laundering
Other
No waivers are requested/needed

Form I-854 (Rev. 09/25/06)Y Page 2

Part B. Certifications.
1. Alien Certification. (S classification request.)
I certify under penalty of perjury that I have reviewed with the LEA all the information in Part A, disclosed all information to the
best of my ability, and disclosed all reasons for which I may be removed from the United States; that I shall report at least every
three months my whereabouts and activities as the above LEA shall require; that I understand I am subject to removal for any
grounds of inadmissibility (conduct or condition) not disclosed at this time or for conduct committed after admission to the United
States; that I shall abide by all conditions, limitations and restrictions imposed upon my entry; that the classification I seek is
temporary and will terminate within three (3) years; that I am restricted by the terms of my admission to very specific means by
which I will be able to remain permanently in the United States; that I will pay Social Security and all applicable taxes on all
employment in the United States; and that I hereby waive my right to a removal hearing and to contest, other than on the basis of
an application for withholding of removal, any action for deportation instituted against me.
Certification: I certify that I have read and understand all the questions and statements on this form. If I do not understand
English, I further acknowledge that this has been read to me in a language I do understand. The answers I have furnished
are true and correct to the best of my knowledge and belief.

Date (mm/dd/yyyy)

Signature

LEA Witness

Translator
2. LEA Certification.

Title

Date (mm/dd/yyyy)

DRAFT
Language Used

Date (mm/dd/yyyy)

I certify the above information is true and correct to the best of my knowledge; that I may make, have made, and will make no
promises regarding the above alien's ability to adjust status or stay permanently in the United States other than those that comport
with section 101(a)(15)(S) of the Act; that I will collect quarterly reports detailing the above alien's whereabouts and activities and
forward required information to the Criminal Division; that I will immediately report to U.S. Immigration and Customs
Enforcement, DHS if this alien fails to report quarterly or fails to comply or to cooperate with the terms and conditions of
admission or if the alien commits any removable activity after the date of admission. I further certify that I assume complete law
enforcement responsibility for control and continued stay in lawful status of the alien, including necessary monitoring, travel
arrangements for arrival and departure, safety precautions and specified conditions of stay or departure; that I have provided a
sworn declaration as to the basis of this application and checked all available database information on the above alien, and that I
have carefully reviewed the above statements with the alien to ensure that all terms and conditions are understood.
Translation. (This serves to verify the alien's certification of translation. See Page 2, Part B.1. of this form.)

Signature of HQ Chief of LEA

Name of Agency Contact

Title of Certifier

Date (mm/dd/yyyy)

Phone No. (Including Area Code)

Form I-854 (Rev. 09/25/06)Y Page 3

3. For United States Attorney Use Only. (if applicable)
Because the alien's presence is essential to the success of a Federal or State investigation or prosecution, the United States
Attorney recommends the above request be granted and further certifies that there has not been and will not be any promises at all
regarding the above alien's ability to adjust status or stay permanently in the United States, other than those that comport with
section 101(a)(15)(S) of the Act.

Signature

Date (mm/dd/yyyy)

Office

Phone No.(Including Area Code)

4. For U.S. Department of State/Rewards Committee - S6 Classification use only.
After checking all information, the U.S. Department of State:
Certifies the alien is eligible to receive an award under 22 U.S.C 2708(a).
Certifies the alien is not eligible for such award.

Signature

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Phone No.(Including Area Code)

DRAFT

Title

Office

Part C. For Department of Justice, Criminal Division Use Only.

After checking and evaluating all waiver and other information available, the Department of Homeland Security, U.S. Immigration
and Customs Enforcement and Department of Justice, Criminal Division:
Certify that, pursuant to section 101(a)(15)(S) of the Act and the request of the above LEA, the above alien is recommended for
the S classification requested, that the above request(s) for waivers of inadmissibility appear to warrant approval, that all
conditions and limitations of the request for classification are attached, that this request falls within the numerical limitation for
an S visa and that, therefore, this request is forwarded to the Assistant Secretary of Immigration and Customs Enforcement for
approval.
Deny request.

Signature

Date (mm/dd/yyyy)

Title

Office

Phone No.(Including Area Code)

Form I-854 (Rev. 09/25/06)Y Page 4

Part D. For U.S. Immigration and Customs Enforcement Use Only.
Fee Received (If applicable).

Request Denied.

Request Granted

Waiver(s) of Grounds of Inadmissibility.
Note all grounds waived and conditions attached thereto.

Signature

Date (mm/dd/yyyy)

Title

Office

Phone No.(Including Area Code)

Part E. For U.S. Citizenship and Immigration Services Use Only.
LEA Request:

Granted.

Forward to DOS/VO.

Denied.

Change of Classification Granted.

Denied.

Date (mm/dd/yyyy)

Signature

Phone No.(Including Area Code)

DRAFT

Title

Office

Part F. For Department of State/Visa Office Use Only.
Forwarded to Consul by VO for Visa Approval.

Not Forwarded.

Signature

Date (mm/dd/yyyy)

Title

Office

Phone No.(Including Area Code)

Visa Granted.
Visa Denied.

Title

Signature

Date (mm/dd/yyyy)

Office

Form I-854 (Rev. 09/25/06)Y Page 5

Part G. Request to allow an S Nonimmigrant to file for adjustment of status to permanent resident.
(For Department of Justice, Criminal Division Use Only.)
(Please attach all relevant documentation establishing (1) the information certified below; (2) the recommendations and reasons for
the certified recomendations.)
1. Name of LEA:

submitting request to allow an S nonimmigrant to
file for adjustment of status.

Date Submitted (mm/dd/yyyy)

2. Criminal Division (Assistant Attorney General) Certifications.
has -

I certify that (alien's name)
If S-5:

Supplied the information that formed the basis of entry;
The information substantially contributed to the success of an authorized criminal investigation or the
prosecution of an individual as per terms of entry.

If S-6:

Supplied the information that formed the basis of entry;
The information substantially contributed to the prevention or frustration of an act of terrorism against a
U.S. person or property or the success of an authorized criminal investigaton of, or the prosecution of,
an individual involved in such an act of terrorism.
Has received a reward under section 36(a) of the State Department Basic Authorities Act of 1956;

If S-5 or S-6:
Other Comments:

Has abided by all the terms, conditions and specific 22 U.S.C. 2708(a) limitations of the S classification.

DRAFT

Signature

Date (mm/dd/yyyy)

Title

Office

Phone No.(Including Area Code)

3. For U.S. Citizenship and Immigration Services Use Only.
Adjustment.

Other Action.

Signature

Date (mm/dd/yyyy)

Title

Office

Phone No.(Including Area Code)

Form I-854 (Rev. 09/25/06) Y Page 6