Form 1 Certificaiton Instrument

OMB Control Number: 0970-0454
Expiration date: 02/28/2022

Information Requested for Foreign Adult Human Trafficking Victims Seeking HHS Certification
HHS provides letters of certification and eligibility to foreign national victims of severe forms of human trafficking
under the authority of the Trafficking Victims Protection Act of 2000, as amended, 22 U.S.C. Section 7105(b)(1)(C)
and (E). This form can be used to provide information to obtain a Certification Letter from HHS. Certification is
required for foreign adult victims of human trafficking in the United States to apply for federally funded benefits and
services.
Do not use this form for minors with Continued Presence or a T Nonimmigrant visa. To obtain a HHS Eligibility
Letter for a foreign trafficking victim under 18 years of age, contact [email protected] for assistance.
This form is not an application. Use of this form is optional. If you do not wish to use this form and would like to
obtain a HHS Certification Letter, please contact a HHS Trafficking Specialist at 866-401-5510 or email
[email protected].
INSTRUCTIONS AND OVERVIEW FOR CERTIFICATION PROCESS
1. Please read entire form before completing it.
2. Fill out all sections that apply to the person who experienced trafficking.
3. Send the completed form and supporting documentation (e.g. T-1 Nonimmigrant Status (T-1 Visa) to
[email protected] with the subject line as "HHS Certification Request."
4. To further protect the confidentiality of the communication, you can transmit the form as a passwordprotected PDF and send the password in a separate email to [email protected].
To protect privacy,do not include personal information (e.g., name, alien number) about the client in the subject line
or body of the emails.
HHS will issue a Certification Letter after receiving the information provided in this form and the supporting
document. If HHS needs additional information, a HHS representative will contact you.
Questions? Contact a HHS Trafficking Specialist at 866-401-5510 during regular business hours, Monday through
Friday, 8:00 a.m. to 5:00 p.m. Eastern Time, or email [email protected].
The National Human Trafficking Hotline at 1-888-373-7888 is available 24 hours a day, 7 days a week for technical
assistance and service referrals.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average .5 hours per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Section 1: Client Information
Client's Initials

Alien Number

Country of Origin

Date of Birth (MM/DD/YYYY)

Sex

Type of Trafficking Experienced

Male

Sex Trafficking

Female

Labor Trafficking
Both

Section 2: Case Management/Requestor Information
Please complete Section 1 if you are the client's case manager. If not, then go to Section 2.
Case Manager's/Requestor's Name
Last

First

Middle

Title
Name of Agency/Organization

Phone

Extension

Email
Address
City

State

Zip Code

I agree to receive the HHS Certification Letter and to provide it to the client without
delay upon receipt.

Section 3: Case Management Services
HHS funds the Trafficking Victim Assistance Program (TVAP). TVAP provides case management services, including
referrals and emergency assistance, for foreign national persons who have experienced trafficking and are seeking
HHS Certification. It can also assist recipients of HHS Certification and certain family members with accessing
federal and state benefits and services.
Please indicate the client's preference regarding access to TVAP services:
Yes, I would like to be connected with a TVAP provider.
No, I do not want to be connected with a TVAP provider at this time.
Primary Language

Please describe below any emergency needs (e.g., housing, medical care, or food):

If "yes" is selected above, please provide the city and state where the client resides so that a case manager can be
identified who is located near the client.
City

State

Zip Code

Section 4: Request Certification Letter
Please indicate to whom the Certification Letter should be mailed and the recipient's mailing address:
Client

Case Manager

Address
City

State

Benefits Start Date (MM/DD/YYYY)

(Do not provide a date later than two weeks from the date of submission of this form.)
Please submit with this form one of the following documents:
Continued Presence that has not been rescinded,
Current T-1 Nonimmigrant Status, or
Bona Fide T-1 Visa that has not been denied.

Zip Code

Important Notice Regarding Information Sharing
Please read the following information. If this form is not in the victim's primary language or if the victim is unable to
read or understand the form, the representative should read and explain the form to the individual in his or her
primary language or use a qualified interpreter to do so. This notification is intended to inform the victim of how the
information provided will be used by HHS.
The Department of Health and Human Services (HHS) is a federal government agency that is responsible for
identifying and assisting potential victims of human trafficking. HHS provides letters of certification and eligibility to
foreign national victims of severe forms of human trafficking, making them eligible to receive federal and state
benefits to the same extent as a refugee.
HHS provides letters of certification and eligibility to foreign national victims of severe forms of human trafficking
under the authority of the Trafficking Victims Protection Act of 2000 (TVPA), as amended 22 U.S.C. Section 7105(b)
(1)(C) and (E).
HHS will use the information collected in the HHS Certification form for one or more of the following purposes, and to
comply with the TVPA:
1.
2.
3.

To coordinate the delivery of a HHS Certification Letter to a foreign adult present in the United States who has
been subjected to a severe form of trafficking in persons;
To refer a foreign adult victim of trafficking in the United States to a case manager to assist
the person in obtaining needed benefits and services; and
To report aggregated data on trafficking victims assisted by HHS in federal reports and to the public.

HHS will not share any personally identifiable information such as the victim's name or alien number for reports or
publicly available data sets. The information contained in the form may be disclosed for a legitimate law enforcement
purpose, including in response to a discovery request or otherwise in the course of criminal or civil litigation. If you
have any questions about this form, you may contact a HHS Trafficking Specialist at 866-401-5510 or
[email protected].
By signing this form, you acknowledge that the victim gives consent to share the information contained in the HHS
Certification form as necessary to obtain HHS Certification and for reporting purposes. The victim acknowledges that
they have been notified that their information will be used in federal reports or data that is available to the public in a
way that does not disclose personally identifiable information and is generally reported in aggregate data.
By signing this form, you acknowledge that the victim has been informed that the information provided in this form
might be shared with other federal agencies as part of aggregated data reporting, and with public and
nongovernmental organizations for the purpose of confirming eligibility for benefits, or for referral to a TVAP provider.
Requestor's Signature: ____________________________________________
Date: _____________________________