Table of Changes - Form I-854B

TABLE OF CHANGES – FORM

FORM I-854B

Inter-Agency Alien Witness and Informant Adjustment of Status

OMB Number: 1615-0046

Submission Date 12/05/2013

Reason for Revision: Form I-854 is being split up into two forms, I-854A (Inter-Agency Alien Witness and Informant Record) and I-854B.

Current Section and Page Number	Current Text	Proposed Text
[NEW] Page 1	[Same as Part A. Numbers 1 – 4 in Form I-854A.]	START HERE – Type or print in black ink. 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 E-mail Address 5. In the space below, provide all the requested information for the alien for which adjustment of status 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 Name(s) 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
Page 2	[Form I-854, Page 6, Part G moved to Page 2 of this Form.]	Part 2. Certifications Attach all relevant documentation establishing (1) the information certified below and (2) the recommendations and reasons for the certified recommendations. LEA Certification I certify the above information is true and correct to the best of my knowledge; that no promises have been made regarding the above alien’s ability to adjust status or stay permanently in the United States other than those that comport with INA section 101(a)(15)(S); that I have collected quarterly and annual year reports detailing the above alien’s whereabouts and activities and forwarded required information to the Department of Justice, Criminal Division; and that the alien has fulfilled the terms of his or her admission and classification.  With this certification, I recommend the above mentioned person for adjustment of status under section 245(j) of the INA.  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 The Department of Justice, Criminal Division (Assistant Attorney General) Certifications I certify that the alien, [ ], has – If S-5, S-6, or S-7: Abided by all terms and conditions of the S classification. If S-5:  Substantially contributed information to the success of an authorized criminal investigation or the prosecution of an individual as per terms of entry.  Supplied the information that formed the basis of entry. If S-6:  Substantially contributed information to the prevention or frustration of an act of terrorism against a U.S. person or property or the success of an authorized criminal investigation of, or the prosecution of, an individual involved in such an act of terrorism;  Supplied the information that formed the basis of entry.  Received a reward under section 36(a) of the State Department Basic Authorities Act of 1956.  Abided by all specific 22 U.S.C. 2708(a) limitations of the S classification. If S-7:  The S-5 or S-6 alien through which this alien obtained S classification through has abided by all terms, conditions of the S classification, and is recommended for adjustment. Other Comments: ___________________________________ 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 For U.S. Citizenship and Immigration Services Use Only __Adjustment Granted __ Adjustment 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

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