Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons

OMB No. 1615-0099; Expires 05/31/2014
Department of Homeland Security
U.S. Citizenship and Immigration Services

Instructions for Form I-914, Supplement B, Declaration of
Law Enforcement Officer for Victim of Trafficking in Persons
Instructions

Read these instructions carefully to properly complete this form. If you need more space to complete an answer, use a separate
sheet of paper. Write the victim's name and Alien Registration Number (A-Number), if known, at the top of each sheet of
paper and indicate the part and number of the item to which the answer refers.

What Is the Purpose of This Form?
Federal, State, and local law enforcement officers should use
Form I-914, Supplement B, to certify that an individual (the
applicant) submitting Form I-914, Application for T
Nonimmigrant Status, is a victim of a severe form of
trafficking in persons.

When Should I Use Form I-914, Supplement B?
If you, the certifying Federal, State, or local law enforcement
official, determine that this individual is or has been a victim
of a severe form of trafficking in persons, you may complete
this supplement form. The applicant will then submit the
supplement to USCIS with his or her application for T
nonimmigrant status.
You must complete the form based upon your knowledge of
the case, including evidence developed by other law
enforcement officers investigating the case.
To be eligible for T nonimmigrant status, the applicant must
demonstrate that he or she is present in the United States as a
result of being a victim of a severe form of trafficking in
persons. Unless the applicant is under 18 years of age, he or she
must also show that he or she has complied with any reasonable
requests from Federal, State, or local law enforcement in the
investigation or prosecution of the trafficking crime of which
he or she was a victim. These elements may be established
without submitting Form I-914, Supplement B, but submission
of the Supplement B is strongly advised.

Instructions
1. Type or print legibly in black ink.
2. If extra space is needed to complete any item, attach an
additional sheet of paper. Write the victim's name and ANumber, if known, at the top of each sheet of paper and
indicate the part and number of the item to which the
answer refers.
3. Answer all questions fully and accurately. State that an
item is not applicable with “N/A.” If the answer is none,
write “None.”

This form is divided into Parts A through F. The following
information will help you fill out the form:
Part A. Victim Information
1. Family Name (Last Name) - Give victim's legal name.
2. Given Name (First Name) - Give victim's full first
name; do not use "nicknames." (Example: If victim's
name is Albert, do not use Al.)
3. Other Names Used - Provide all the names the victim
has used that you are aware of, including maiden name
if applicable, married names, nicknames, etc.
4. Date of Birth - Use eight numbers to show the victim's
date of birth (example: May 1, 1979, should be written
05/01/1979).
5. Gender - Check the appropriate box.
6. Alien Registration Number (A-Number) - Provide
the USCIS (former INS) file number if there is one,
and if it is known to you.
7. Social Security Number - Provide the Social Security
Number if there is one, and if it is known to you.
Part B. Agency Information
1. Name of Certifying Agency - The certifying agency
must be a Federal, State, or local law enforcement
agency, prosecutor, or authority, or Federal or State
judge that has responsibility for the investigation or
prosecution, conviction, or sentencing of the
trafficking in persons of which the applicant was a
victim.
2. Name of Certifying Official - Give your name, title,
and division or office.
3. Agency Address - Give the agency's mailing address.
4. Agency Type - Mark the appropriate box.
5. Case Information - Provide the case status
information and case identification number, if
applicable.
Form I-914, Supplement B, Instructions (Rev. 05/04/12) Y

Part C. Statement of the Claim
In order to qualify for T nonimmigrant benefits, the
individual must be or have been a victim of a severe form
of trafficking in persons. Mark the box that describes the
individual's victimization.

An alien victim is prohibited from filing for derivative T
nonimmigrant status on behalf of a family member who
participated in trafficking the alien victim that established
his or her eligibility for T nonimmigrant status. Therefore,
USCIS will not grant an immigration benefit to a family
member who committed trafficking.

1. Sex trafficking in which a commercial sex act was
induced by force, fraud, or coercion.

Part F. Attestation

2. Sex trafficking and the victim is under the age of 18.
3. Recruiting, harboring, transportation, provision, or
obtaining of a person for labor or services through the
use of force, fraud, or coercion for subjection to
involuntary servitude, peonage, debt bondage, or
slavery.
4. Not applicable - You do not believe this individual is a
victim of trafficking.
5. Other - Attach additional sheets to explain.
Describe the victimization and the relationship of the
victimization to the crime under investigation or
prosecution by attaching additional sheets. Attach the
results of any name or database inquiry and any relevant
reports or findings. Explain if the individual has expressed
any fear of retaliation or revenge if removed from the
United States. Attach additional sheets if necessary.
Indicate the dates on which the acts of trafficking
occurred, the statutory citations that are or were being
investigated or prosecuted, the date on which the
investigation or prosecution was initiated, and the date it
was completed, if any.
Part D. Cooperation of the Victim
In order to qualify for T nonimmigrant status, the
individual must show that he or she has complied with
any reasonable requests from Federal, State, or local law
enforcement in the investigation or prosecution of the acts
of trafficking of which he or she was a victim, unless they
are under the age of 18.
Mark the box that describes the individual's cooperation
with you and explain, attaching additional sheets if
necessary.
Part E. Family Members Implicated in Trafficking

NOTE: If the victim unreasonably refuses to assist in the
investigation or prosecution of the acts of trafficking of
which he or she is a victim, even after this form is
submitted to USCIS, you should notify USCIS by sending
a written statement to:
USCIS
Vermont Service Center
75 Lower Welden Street
St. Albans, VT 05479-0001
Include the victim's name, date of birth, and A-Number (if
available) on all correspondence.

Privacy Act Notice
We ask for the information on this form, and associated
evidence, to determine the victim's eligibility for the
immigration benefit being sought. Our legal right to ask for
this information can be found in the Immigration and
Nationality Act, as amended. We may provide this
information to other government agencies.

Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control
number. The public reporting burden for this collection of
information is estimated at 30 minutes per response, including
the time for reviewing instructions and completing and
submitting the form. Send comments regarding this burden
estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: U.S.
Citizenship and Immigration Services, Regulatory Coordination
Division, Office of Policy and Strategy, 20 Massachusetts
Avenue, N.W., Washington, DC 20529-2210. OMB No.
1615-0099. Do not mail your application to this address.

List whether any of the victim's family members are
believed to have been involved in the trafficking in
persons of which the individual is a victim.
Form I-914, Supplement B, Instructions (Rev. 05/04/12) Y Page 2