I-918 B U Nonimmigrant Status Certification

USCIS
Form I-918

Supplement B, U Nonimmigrant Status Certification
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0104
Expires 01/31/2016

Remarks
For
USCIS
Use
Only
► START HERE - Type or print in black or blue ink.

Part 1. Victim Information
1.

Name of Head of Certifying Agency
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

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Alien Registration Number (A-Number) (if any)
► A-

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

4.c. Middle Name

Agency Address

2.c. Middle Name

5.a. Street Number
and Name

Other Names Used (Include maiden names, nicknames, and
aliases, if applicable.)

5.b.

If you need extra space to provide additional names, use the
space provided in Part 7. Additional Information.

5.c. City or Town

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

Apt.

Ste.

5.d. State

5.f.

5.e. ZIP Code

Province

3.c. Middle Name

5.g. Postal Code

4.

Date of Birth (mm/dd/yyyy)

5.h. Country

5.

Gender

Male

Flr.

Female

Other Agency Information

Part 2. Agency Information
1.

6.

Federal

Name of Certifying Agency
7.

Name of Certifying Official
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Title and Division/Office of Certifying Official

Form I-918 Supplement B 01/15/13 N

Case Status
On-going

State

Local

Completed

Other
8.

Certifying Agency Category
Judge

Law Enforcement

Prosecutor

Other

2.c. Middle Name
3.

Agency Type

9.

Case Number

10.

FBI Number or SID Number (if applicable)

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Part 3. Criminal Acts
If you need extra space to complete this section, use the space
provided in Part 7. Additional Information.
1.

The petitioner is a victim of criminal activity involving a
violation of one of the following Federal, state, or local
criminal offenses (or any similar activity). (Select all
applicable boxes)
Abduction

Manslaughter

Abusive Sexual Contact

Murder

Attempt to Commit
Any of the Named
Crimes

Obstruction of Justice
Peonage

4.a. Did the criminal activity occur in the United States
(including Indian country and military installations) or the
territories or possessions of the United States?
Yes

No

4.b. If you answered "Yes," where did the criminal activity
occur?

5.a. Did the criminal activity violate a Federal extraterritorial
jurisdiction statute?
Yes
No
5.b. If you answered "Yes," provide the statutory citation
providing the authority for extraterritorial jurisdiction.

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Being Held Hostage
Blackmail

Conspiracy to Commit
Any of the Named
Crimes
Domestic Violence
Extortion

False Imprisonment
Felonious Assault
Female Genital
Mutilation

Perjury

Prostitution
Rape

Sexual Assault

Briefly describe the criminal activity being investigated
and/or prosecuted and the involvement of the petitioner
named in Part 1. Attach copies of all relevant reports and
findings.

7.

Provide a description of any known or documented injury
to the victim. Attach copies of all relevant reports and
findings.

Sexual Exploitation
Slave Trade

Solicitation to
Commit Any of the
Named Crimes
Stalking
Torture

Fraud in Foreign Labor
Contracting

Trafficking

Incest

Unlawful Criminal
Restraint

Involuntary Servitude

6.

Witness Tampering

Kidnapping

Provide the dates on which the criminal activity occurred.
2.a. Date (mm/dd/yyyy)

2.b. Date (mm/dd/yyyy)
2.c. Date (mm/dd/yyyy)
2.d. Date (mm/dd/yyyy)
3.

List the statutory citations for the criminal activity being
investigated or prosecuted, or that was investigated or
prosecuted.

Form I-918 Supplement B 01/15/13 N

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4.

Part 4. Helpfulness Of The Victim

Other. Include any additional information you would like
to provide.

For the following questions, if the victim is under 16 years of
age, incompetent or incapacitated, then a parent, guardian, or
next friend may act on behalf of the victim.
1.

Does the victim possess information concerning the
criminal activity listed in Part 3.?
Yes
No

2.

Has the victim been helpful, is the victim being helpful, or
is the victim likely to be helpful in the investigation or
prosecution of the criminal activity detailed above?
Yes

3.

No

Since the initiation of cooperation, has the victim refused
or failed to provide assistance reasonably requested in the
investigation or prosecution of the criminal activity
detailed above?
Yes
No

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If you answer "Yes" to Item Numbers 1. - 3., provide an
explanation in the space below. If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.

Form I-918 Supplement B 01/15/13 N

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Part 5. Family Members Culpable In Criminal
Activity
1.

Are any of the victim's family members culpable or
believed to be culpable in the criminal activity of which
the petitioner is a victim?
Yes
No
If you answered "Yes," list the family members and their
criminal involvement. (If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.)

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Part 6. Certification
I am the head of the agency listed in Part 2. or I am the person
in the agency who was specifically designated by the head of
the agency to issue a U Nonimmigrant Status Certification on
behalf of the agency. Based upon investigation of the facts, I
certify, under penalty of perjury, that the individual identified in
Part 1. is or was a victim of one or more of the crimes listed in
Part 3. I certify that the above information is complete, 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
(USCIS), based upon this certification. I further certify that if
the victim unreasonably refuses to assist in the investigation or
prosecution of the qualifying criminal activity of which he or
she is a victim, I will notify USCIS.

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2.c. Middle Name

1.

Signature of Certifying Official

2.

Date of Signature (mm/dd/yyyy)

3.

Daytime Telephone Number

4.

Fax Number

2.d. Relationship

2.e. Involvement

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

3.c. Middle Name
3.d. Relationship

3.e. Involvement

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name
4.d. Relationship

4.e. Involvement

Form I-918 Supplement B 01/15/13 N

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5.a. Page Number

Part 7. Additional Information
If you need extra space to complete any item within this
supplement, use the space below or attach a separate sheet of
paper; type or print the agency's name, petitioner's name, and
the Alien Registration Number (A-Number) (if any) at the top
of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and sign and date
each sheet. If you need more space than what is provided, you
may also make copies of this page to complete and file with this
supplement.
1.

5.b. Part Number

5.c. Item Number

5.d.

Agency Name

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Petitioner's Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

2.c. Middle Name
3.

A-Number (if any)

► A-

4.a. Page Number

4.b. Part Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

4.c. Item Number

6.d.

4.d.

Form I-918 Supplement B 01/15/13 N

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