Form I-854A Interagency Alien Witness and Informant Record

Inter-Agency Alien Witness
and Informant Record

USCIS
Form I-854A

OMB No. 1615-0046
Expires 03/31/2017

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

4.

Street Number and Name

Apt. Ste. Flr.

City or Town

State

Contact Information
Daytime Telephone Number

5.

ZIP Code

E-mail Address

Fax Number

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 no danger to people or property of the United States.
If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish.
Investigation.
6.

Prosecution.

United States Attorney involvement.

Type of Requests. (Attach legal basis for request.)
S-5

S-6

S-7

Consular post at which visa will be sought:

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)

Form I-854A 03/13/15 N

Given Name (First Name)

Middle Name

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Part 1. To be completed by Law Enforcement Agencies (continued)
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
Alien Registration Number
(A-Number) (if any)

S-Visa Number

Passport Number

Form I-94 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)

Date of Birth (mm/dd/yyyy)

Class of Admission

Current Immigration Status
Place of Birth
Country of Origin
Gender
Male

Female

Occupation

Country of Citizenship or Nationality
Marital Status
Married

Never Married

Separated

Divorced

Select all documents attached:
Form G-325

8.

Widowed

Form FD-258

Photos

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,” explain below.
Yes

Form I-854A 03/13/15 N

No

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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.)
Crime involving moral turpitude [212(a)(2)(A)(I)]

Prostitute and/or procurer of prostitution [212(a)(2)(D)]

International child abduction [212(a)(10)(C)]

Unlawful activity related to national security
[212(a)(3)(A)]

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)(i)]
Coming to overthrow the U.S. Government
[212(a)(3)(A)(iii)]
Money laundering [212(a)(2)(I)]
Previously removed-aggravated felony
[212(a)(9)(A)(i)]
Nonimmigrant without a valid passport or visas
[212(a)(7)(B)(ii)]
Previously excluded and deported or removed
[212(a)(9)(A)]
Alien smuggler [212(a)(6)(E)]
Convicted of law pertaining to controlled substance
[212(a)(2)(A)(i)(II)]

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)]
Drug abuser or addict [212(a)(1)(A)(iv)]
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; indicate the Page Number, Part Number, and Item Number to which your
answer refers; and sign and date each sheet.

Form I-854A 03/13/15 N

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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 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.

Form I-854A 03/13/15 N

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Part 2. Certifications (continued)
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

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

Form I-854A 03/13/15 N

ZIP Code

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Part 3. For United States Attorney Use Only (if applicable) (continued)
Office Contact Information
Daytime Telephone Number

E-mail Address

Fax Number

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

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 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

Form I-854A 03/13/15 N

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Part 5. For Department of Justice, Criminal Division Use Only (continued)
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

Part 6. For U.S. Citizenship and Immigration Services Use Only
LEA Request:

Granted

Forwarded to DOS/Visa Office (VO)

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

Form I-854A 03/13/15 N

Fax Number

E-mail Address

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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

Visa Granted

Fax Number

E-mail Address

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

Form I-854A 03/13/15 N

Fax Number

E-mail Address

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