Form I-854B Agency Alien Witness and Informant Adjustment of Status

Inter-Agency Alien Witness and
Informant Adjustment of Status

USCIS
Form I-854B

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

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

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.)

3.

Mailing Address

4.

Street Number and Name

Apt. Ste. Flr.

City or Town

State

ZIP Code

Contact Information
Daytime Telephone Number

5.

Control Agent

Fax Number

E-mail Address

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 Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable)
Family Name (Last Name)

Given Name (First Name)

Middle Name

C. Mailing Address
Street Number and Name
City or Town

Apt. Ste. Flr.
State

ZIP Code

Current Location of Alien (City, State)

D. Other Information
S-Visa Number

Passport Number

Form I-854B 03/13/15 N

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

Form I-94 Number

Travel Document Number

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Part 1. To be completed by Law Enforcement Agencies (continued)
D. Other Information (continued)
Country of Issuance for Passport or Travel
Document

Expiration Date for Passport or
Travel Document (mm/dd/yyyy)

Place of Last Entry into the U.S. (City, State)

Date of Birth (mm/dd/yyyy)

Date of Last Entry into the U.S.
(mm/dd/yyyy)
Class of Admission

Current Immigration Status
Place of Birth
Country of Origin
Gender
Male

Female

Country of Citizenship or Nationality
Marital Status
Married

Occupation

Never Married

Separated

Divorced

Widowed

Select all documents attached:
Form G-325

Form FD-258

Photos

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 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

Form I-854B 03/13/15 N

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Part 2. Certifications (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

The Department of Justice, Criminal Division (Assistant Attorney General) Certifications
I certify that the alien,
If S-5, S-6, or S-7:
If S-5:

, has Abided by all terms and conditions of the S classification.

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

Title

Name

Date (mm/dd/yyyy)

Form I-854B 03/13/15 N

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Part 2. Certifications (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

E-mail Address

Fax Number

For U.S. Citizenship and Immigration Services Use Only
Adjustment Granted

Adjustment Denied

Signature

Date (mm/dd/yyyy)

Name

Title

Office Contact Mailing Information
Office Name
Street Number and Name

Apt. Ste. Flr.

City or Town

State

ZIP Code

Office Contact Information
Daytime Telephone Number

Form I-854B 03/13/15 N

Fax Number

E-mail Address

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