Declaration of Law Enforcement Officer for Victim of trafficking in Persons (Contact by Respondent to Law Enforcement)

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

What Is the Purpose of This Form?
Federal, State, and local law enforcement officials should use
Form I-914, Supplement B, Declaration of Law Enforcement
Officer for Victim of Trafficking in Persons, to provide
evidence to United States Citizenship and Immigration Services
(USCIS) that you believe an individual (the applicant)
submitting Form I-914, Application for T Nonimmigrant Status,
is a victim of a severe form of trafficking in persons and has
cooperated with your reasonable requests for assistance in an
investigation or prosecution of a crime where trafficking is at
least one central reason for the commission of that crime.
USCIS (not the Federal, State, or local law enforcement
official) will make the decision if the applicant meets the
eligibility requirements for T nonimmigrant status.

To be eligible for T nonimmigrant status, the applicant must
demonstrate to USCIS that he or she:
1. Is or was a victim of a severe form of trafficking in persons
(see Form, Part C, Statement of Claim, for a definition);

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By signing the Form I-914, Supplement B, you are not
conferring an immigration benefit. USCIS is the only agency
that can approve the applicant's Form I-914. USCIS requires
fingerprints and police clearances from the victim and conducts
background and security checks. The applicant must submit
other evidence in addition to the Form I-914, Supplement B.
The certifying Federal, State, or local law enforcement agency
will not be subject to any liability.

When Should I Use Form I-914, Supplement B?

If you, the certifying Federal, State, or local law enforcement
official, believe that this individual is or has been a victim of a
severe form of trafficking in persons and has cooperated with
your reasonable requests for assistance in your investigation or
prosecution, you may complete this supplement form. You
should complete all fields of this form yourself. The
Supplement B must be signed with an original signature. A
photocopy of a signed application or a typewritten name in
place of a signature is not acceptable. The applicant will then
submit Form I-914, Supplement B 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 involved with the case.
You do not need to formally launch an investigation or file
charges to complete the Form I-914, Supplement B. You may
complete the Form I-914, Supplement B if an investigation does
not lead to an arrest or a prosecution. Completing the Form
I-914, Supplement B is not contingent on the outcome of a
prosecution or investigation. Completing the Form I-914,
Supplement B is at your discretion. There is no statute of
limitations related to completing the Form I-914, Supplement B.
Your agency may have its own procedures related to completing
the Form I-194, Supplement B.

2. Is present in the United States as a result of being a victim of a
severe form of trafficking in persons (including physical
presence based on having been allowed entry into the United
States to participate in investigative or judicial processes
associated with an act or perpetrator of trafficking);
3. 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; unless
a. the applicant is under the age of 18; or
b. he or she is unable to cooperate due to physical or
psychological trauma; and

4. Would suffer extreme hardship involving unusual and severe
harm upon removal from the United States.
These qualifying elements may be established without
submitting Form I-914, Supplement B, but submission of the
Supplement B is one piece of evidence. USCIS (not the
certifying Federal, State, or local law enforcement official)
makes the determination on whether the evidence is sufficient
and whether the applicant meets each eligibility requirement.

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. Full Name. Give victim's legal name, as shown on his or
her birth certificate or legal name change document.
2. 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.
3. Date of Birth. Use eight numbers to show the victim's date
of birth (example: May 1, 1979, should be written
05/01/1979).
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4. Gender. Check the appropriate box.
5. Alien Registration Number (A-Number). Provide the
USCIS (former INS) file number if there is one, and if it is
known to you.
6. Social Security Number. Provide the Social Security
Number if there is one, and if it is known to you.

5. List the statutory citations that are or were being
investigated or prosecuted.
6. Provide the date on which the investigation or prosecution
was initiated.
7. Provide the date on which the investigation or prosecution
was completed, if any.

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Part B. Agency Information

Part D. Cooperation of Victim

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.

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 he or she is under the age of 18 or
he or she is unable to cooperate with the request due to physical
or psychological trauma).

2. Name of Certifying Official. Give your name, title, and
division or office.
3. Agency Address. Give the agency's mailing address.

4. Daytime Phone Number and Fax Number. Give your
phone number and fax number with area code.
5. Agency Type. Mark the appropriate box.

6. Case Information. Provide the case status information and
case identification number, if applicable.
Part C. Statement of Claim

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

B. Sex trafficking and the victim is under the age of 18.
C. 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. You do not believe this individual is a
victim of trafficking.
E. Other. Attach additional sheets to explain.
2. Describe the victimization on which the applicant's claim is
based and identify 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. Attach
additional sheets if necessary.
3. Explain if the individual has expressed any fear of
retaliation or revenge if they are removed from the United
States.

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
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.

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.
Part F. Attestation

The law enforcement officer filling out this form (identified in
Part B of the form), and their supervisor, must sign and date the
form in this section.
The Form I-914, Supplement B must have an original signature.
A photocopy of a signed certification or a type written name in
place of a signature is not acceptable.

How Can I Provide Further Information at a Later Date?
An agency can provide further information to USCIS or
formally revoke the Form I-914, Supplement B at a later date,
even after this form is submitted to USCIS, if there is new
information or if the victim is no longer cooperating with a
reasonable request for assistance in an investigation or
prosecution. You should notify USCIS by sending a written
statement to:
USCIS
Vermont Service Center
75 Lower Welden Street
St. Albans, VT 05479-0001

4. Provide the dates on which the acts of trafficking occurred.

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An agency should send a letter on official agency letterhead to
USCIS at the address above describing the reasons for
providing further information or the reasons for revoking the
certification. Include the victim's name, date of birth, and
A-Number (if available) on all correspondence. USCIS will
allow the victim to rebut this information.

USCIS Privacy Statement

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 law enforcement
agencies for this collection of information is estimated at 3
hours and 30 minutes per response, including the time for
reviewing instructions and completing and submitting the form.
The public burden for the Form I-914 respondents who will take
the action of contacting a law enforcement agency to request
that Form I-914, Supplement B be completed is estimated to
require 15 minutes to make such a request to the agency. 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 NW, Washington, DC
20529-2140. OMB No. 1615-0099. Do not mail your
completed Form I-914, Supplement B to this address.

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AUTHORITIES: The information requested on this form, and
associated evidence, is collected under the Immigration and
Nationality Act, section 101, et seq.
PURPOSE: The primary purpose for providing the requested
information is to provide the applicant (the victim) with
evidence for the immigration benefit for which he or she is
filing.

DISCLOSURE: The information you provide is voluntary.
However, failure to provide the requested information, and any
requested evidence, may delay a final decision or result in
denial of the applicant's form.

ROUTINE USES: The information you provide on this form
may be shared with other Federal, State, local, and foreign
government agencies and authorized organizations following
approved routine uses described in the associated published
system of records notices [DHS-USCIS-007 - Benefits
Information System and DHS-USCIS-001 - Alien File,
Index, and National File Tracking System of Records, which
can be found at www.dhs.gov/privacy]. The information may
also be made available, as appropriate, for law enforcement
purposes or in the interest of national security.

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