Form I-914B Declaration of Law Enforcement Officer for Victim of tra

OMB No. 1615-0099; Expires 05/31/2014

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

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

For USCIS Use Only

START HERE - Type or print in blank ink. This form should be completed by
Federal, State, or local law enforcement authorities for victims under the Victims of
Trafficking and Violence Protection Act, Public Law 106-386, as amended.

Returned

PART A. Victim Information

Date

Receipt

Draft
Not for
Production
06/17/2013

Family Name (Last Name)

Given Name (First Name)

Middle Name (if any)

Date
Resubmitted

Other Names Used (include maiden name/nickname)

Date

Date of Birth (mm/dd/yyyy)

Gender

Male

A-Number (if known)

Part B.

Female

Social Security Number (if known)

Date
Reloc Sent
Date

Date
Reloc Rec'd

Agency Information

Name of Certifying Agency

Date

Name of Certifying Official

Title and Division/Office of Certifying Official Date

Remarks

Agency Address - Street Number and Name
City

Suite Number

State/Province

Daytime Phone No. (area code and/or extension)

Agency Type
Federal

State

Local

Case Status
On-going

Completed

Local

Certifying Agency Category
Judge
Law Enforcement
Case Number

ZIP/Postal Code

Fax No. (with area code)

Prosecutor

Other

FBI No. or SID Number (if applicable)

Part C. Statement of Claim
1. The applicant is or has been a victim of a severe form of trafficking in persons.
Specifically, he or she is a victim of: (Check all that apply. Base your analysis on the
practices to which the victim was subjected rather than on the specific violations
charged, the counts on which convictions were obtained, or whether any prosecution
resulted in convictions. Note that the definitions that control this analysis are not the
elements of criminal offenses, but are those set forth at 8 CFR 214.11(a).)
A. Sex trafficking in which a commercial sex act was induced by force, fraud, or
coercion. Sex trafficking means recruiting, harboring, transporting, providing,
or obtaining of a person for the purpose of a commercial sex act.
Form I-914, Supplement B (06/17/13) N

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Part C. Statement of Claim

(Continued)

B. Sex trafficking and the victim is under the age of 18.
C. The recruiting, harboring, transporting, providing, 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.
D. Not applicable.

Draft
Not for
Production
06/17/2013

E. Other, specify on attached additional sheets.

2. Please describe the victimization upon which the applicant's claim is based and identify the relationship between that victimization
and the crime under investigation/prosecution. Attach the results of any name or database inquiry performed in the investigation of
the case, as well as any relevant reports and findings. Include relevant dates, etc. Attach additional sheets, if necessary.

3. Has the applicant expressed any fear of retaliation or revenge if removed from the United States? If yes, explain. Attach additional
sheets, if necessary.

4. Provide the date(s) on which the acts of trafficking occurred.
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

5. List the statutory citation(s) for the acts of trafficking being investigated or prosecuted, or that were investigated or prosecuted.

6. Provide the date on which the investigation or prosecution was initiated.
Date (mm/dd/yyyy)

7. Provide the date on which the investigation or prosecution was completed (if any).
Date (mm/dd/yyyy)

Form I-914, Supplement B (06/17/13) N

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Part D. Cooperation of Victim (Attach additional sheets, if necessary)
The applicant:
Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has not been requested to assist in the investigation/prosecution of any crime of trafficking.

Draft
Not for
Production
06/17/2013

Has not yet attained the age of 18.

Other, specify on attached additional sheets.

Part E. Family Members Implicated In Trafficking
Yes

No

Are any of the applicant's family members believed to have been involved in his or her trafficking to the United
States? If "Yes," list the relative(s) and describe the involvement. Attach additional sheets if necessary.
Full Name

Relationship

Involvement

Part F. Attestation
Based upon investigation of the facts, I certify, under penalty of perjury, that I believe the above noted individual is or has been a
victim of a severe form of trafficking in persons as defined by the VTVPA. I certify that the above information is true and correct to
the best of my knowledge, and that I have made, and will make, no promises regarding the above victim's ability to obtain a visa from
U.S. Citizenship and Immigration Services, based upon this certification. I further certify that if the victim unreasonably refuses to
assist in the investigation or prosecution of the acts of trafficking of which he/she is a victim, I will notify USCIS.
Signature of Law Enforcement Officer (identified in Part B)

Date (mm/dd/yyyy)

Signature of Supervisor of Certifying Officer

Date (mm/dd/yyyy)

Printed Name of Supervisor

Form I-914, Supplement B (06/17/13) N

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