Table of Changes - Form I-854A

Table of Changes- Form

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

OMB No.1615-0046

12/05/2013

Reason for Revision: Extending form with minor changes to instructions, including an updated PAS.

Page Number and Current Section	Current Text	Proposed Text
Page 1, Part A. To be completed by Law Enforcement Agencies	Part A. To be completed by Law Enforcement Agencies (See instructions for specific information.) Information must be Typed or Printed clearly. Name of LEA/Requestor: Requesting Agent: Control Agent: Address: Phone No.(Including Area Code): Fax No.(Including Area Code): Check if applicable: Alien will be placed in danger in  U.S.  abroad as a result of providing information, etc. Alien poses…. U.S. If the alien… Investigation. Prosecution. 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____ __ Adjustment of Status (Go to Part F after completing information in items 5, 6 and 7 below.) __Fees attached (when 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. In the space below, provide all the requested information for the principal alien for whom an S classification is requested. Alien's Name (Last Name, First and Middle) Other Names Used Alien's Address (Street Number and Name) City State or Province Zip/Postal Code A # I-94 # Current Location of Alien Marital Status Date of Birth (mm/dd/yyyy) Place of Birth (City or Country) Citizenship/Nationality Occupation Date of Last Entry into U.S. (mm/dd/yyyy): Form G-325 attached Form FD-258 attached Photos attached 6. On a separate application… 7. a. 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.) 7.b. 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 Crime involving moral turpitude… ****	Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.) 1. Name of Law Enforcement Agency (LEA)/Requestor 2. Requesting Agent (Special Agent in Charge, Chief of Police, etc.) Control Agent 3. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code 4. Contact Information Daytime Telephone Number Fax Number Email Address 5. Select all applicable boxes. As a result of providing information, the alien will be placed in danger:  [ ] in the United States or [ ] abroad. The alien poses….United States. If the alien… Investigation. Prosecution. United States Attorney involvement. 6. Type of Requests. (Attach legal basis for request.) __S-5 __ S-6 _S-7 Consular post at which visa will be sought: [text box] __ Consular post at which visa will be sought:____ __ Change of Status - If change of status is requested, current immigration status is____ 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 LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding security precautions. 7. In the space below, provide all the requested information for the alien for whom an S classification is requested. A. Alien’s Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name B. Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable) Family Name (Last Name) Given Name (First Name) Middle Name [2 lines for Other Names] C. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Current Location of Alien (City, State) D. Other Information S-Visa Number Alien Registration Number (A-Number) (if any) Form I-94 Number Passport Number Travel Document Number Country of Issuance for Passport or Travel Document Expiration Date for Passport or Travel Document (mm/dd/yyyy) Date of Last Entry into the U.S. (mm/dd/yyyy) Place of Last Entry into the U.S. (City, State) Current Immigration Status Class of Admission Date of Birth (mm/dd/yyyy) Place of Birth Country of Origin Country of Citizenship or Nationality Gender Male/Female Marital Status -Married, Never Married, Separated, Divorced, Widowed Occupation Select all documents attached: Form G-325 attached Form FD-258 attached Photos [Delete.] 8. You must provide the following information for each alien named in Item Number 7. A. Has the alien ever committed, ordered, incited, assisted, or otherwise participated in genocide; the use, conscription, or recruitment of a child soldier; Nazi persecution; or while outside of the United States, committed torture or extrajudicial killing? If “Yes,” please explain below. Yes No. [Delete remaining language.] B. For the above named alien, I request waivers for any grounds of inadmissibility that may exist. Below is a non-exhaustive list for possible grounds of inadmissibility. Refer to INA 212(a) for a complete list. (Specify all individual events in which the above named alien was arrested, cited, charged, indicted, convicted, fined or imprisoned, or for which the alien has committed but did not have involvement with any law enforcement entity.) [Delete.] Crime involving moral turpitude [212(a)(2)(A)(I)] International child abduction [212(a)(10)(C)] Multiple criminal convictions [212(a)(2)(B)] Engage in unlawful commercialized vice [212(a)(2)(D)] Involved in espionage, sabotage or laws relating to technology [212(a)(3)(A)(iii)] Money laundering [212(a)(2)(I)] Previously removed-aggravated felony [212(a)(9)(A)] Nonimmigrant without a valid passport or visas [212(a)(2)(A)(I)] Alien smuggler [212(a)(2)(E)] Drug abuser or addict [212(a)(1)(A)(iv)] Convicted of law pertaining to controlled substance [212(a)(2)(A)(i)(II)] Prostitute and/or Procurer of Prostitution [212(a)(2)(D)] Unlawful activity related to National Security [212(a)(3)(A)] Terrorist activities [212(a)(3)(B)] Communist Party member [212(a)(3)(D)] Fraud/Misrepresentation [212(a)(6)(C)(i)] Immigrant without a visa [212(a)(7)] Human Trafficking [212(a)(2)(H)] Ordered, incited, assisted or otherwise participated in the commission of acts of torture or extra judicial killing [212(a)(3)(E)] Controlled substance trafficker [212(a)(2)(C)] Engaged in conduct relating to severed violations of religious freedoms [212(a)(2)(G)] Other No waivers are requested/needed C. Briefly explain below each ground of inadmissibility you selected or other grounds of inadmissibility not included in the list above. If you need extra space to complete this item, attach a separate sheet of paper; type or print the alien’s name and A-Number (if any) at the top of each sheet of paper; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet of paper.
Page 3, Part B. Certifications	Part B. Certifications 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. Signature Date (mm/dd/yyyy) LEA Witness Title Date (mm/dd/yyyy) Translator Language Used Date (mm/dd/yyyy) 2. LEA Certification 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 Title of Certifier Date (mm/dd/yyyy) Name of Agency Contact Phone No. (Including Area Code)	Part 2. Certifications Alien Certification (S classification request) I certify under penalty of perjury that I have reviewed with the LEA all the information in Part 1., disclosed all information to the best of my ability, and disclosed all reasons for which I may be inadmissible to the United States or 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 LEA shall require; that I understand I am subject to removal for any grounds of inadmissibility (conduct or condition) or removability 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; that I understand that such ability to remain in the United States is not guaranteed or promised by the LEA; and that I hereby waive my right to a removal hearing and to contest, other than on the basis of a form for withholding of removal, any action for deportation instituted against me. I also 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. Signature Date (mm/dd/yyyy) Name of Principal Alien Signature of LEA Witness Date (mm/dd/yyyy) Name of LEA Witness Title [ ] Interpreter Services Used (This serves to verify the alien's certification of interpretation.) Signature of Interpreter Date (mm/dd/yyyy) Name of Interpreter Language Used LEA Certification 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 INA; that I will, upon approval of S nonimmigrant status and until adjustment of status is granted or the S nonimmigrant status expires or terminates, collect quarterly and annual reports, pursuant to 8 CFR section 214.2(t), which detail the above alien's whereabouts and activities, and that I will forward required information to my headquarters entity, from which point it will be forwarded to the Department of Justice, Criminal Division; that I will immediately report to my headquarters, Department of Homeland Security, U.S. Immigration and Customs Enforcement, Homeland Security Investigations, and the Department of Justice, Criminal Division 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 form and checked all available databases for derogatory 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. [Moved above Interpreter Signature section.] Signature of Requesting Agent Date (mm/dd/yyyy) Name of Requesting Agent Title of Requesting Agent Signature of Headquarters (HQ) Chief of LEA Date (mm/dd/yyyy) Name of Headquarters (HQ) Chief of LEA Title of Certifier Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 4, Part B. Certifications, 3. For United States Attorney Use Only	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)	Part 3. For U. S. Attorney Use Only (if applicable) Because the alien's presence is essential to the success of a Federal or state investigation or prosecution, the U. S. 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 comply with INA section 101(a)(15)(S). Signature of U.S. Attorney Date (mm/dd/yyyy) Name of U.S. Attorney Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 4, Part C. Certifications, 4. For U.S. Department of State/Rewards Committee – S6 Classification use only	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. Date (mm/dd/yyyy) Signature Date (mm/dd/yyyy) Phone No.(Including Area Code) Title Office	Part 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) Name Title Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 4, Part C. For Department of Justice, Criminal Division Use Only	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) Phone No.(Including Area Code) Title Office	Part 5. For Department of Justice, Criminal Division Use Only After checking and evaluating all waivers and other information available, the Department of Justice, Criminal Division: __ Certifies that, pursuant to INA section 101(a)(15)(S) and the request of the above LEA, the above alien is recommended for the S classification requested, that the above requests 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 Director of U.S. Citizenship and Immigration Services for approval. __ Denies request. Signature Date (mm/dd/yyyy) Name Title Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 5, Part D. For U.S. Immigration and Customs Enforcement Use Only	Part D. For U.S. Immigration and Customs Enforcement Use Only	[Delete Part D.]
Page 5, Part |E. For U.S. Citizenship and Immigration Services Use Only	Part E. For U.S. Citizenship and Immigration Services Use Only LEA Request: Granted Forwarded to DOS/VO Denied Change of Classification Granted Denied Signature Date (mm/dd/yyyy) Phone No.(Including Area Code) Title Office	Part 6. For U.S. Citizenship and Immigration Services Use Only LEA Request: Granted Forwarded to DOS/Visa Office (VO) Denied [Delete.] [Delete.] Signature Date (mm/dd/yyyy) Name Title Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 5, Part F. For Department of State/Visa Office Use Only	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) Phone No.(Including Area Code) Title Office Visa Granted Visa Denied Signature Date (mm/dd/yyyy) Title Office	Part 7. For Department of State/Visa Office Use Only __Forwarded to Consul by VO for Visa Approval __Not Forwarded Signature Date (mm/dd/yyyy) Name Title Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address Visa Granted Visa Denied Signature Date (mm/dd/yyyy) Name Title Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address
Page 6, 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)	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)	[Delete Part G. This Part will be moved to I-854B and will be renamed, Part B.]

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