Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons

Instructions for Supplement B, Declaration of Law Enforcement
Officer for Victim of Trafficking in Persons
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-914B

OMB No. 1615-0099
Expires 04/30/2021

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.

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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.
USCIS may contact you if USCIS has any questions about the information provided in the supplement form.

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. 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 Form I-914, Supplement B. You may
complete Form I-914, Supplement B, if an investigation does not lead to an arrest or a prosecution. Completing Form
I-914, Supplement B, is not contingent on the outcome of a prosecution or investigation. Completing Form I-914,
Supplement B, is at your discretion. There is no statute of limitations related to completing Form I-914, Supplement B.
Your agency may have its own procedures related to completing Form I-914, Supplement B.
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);
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 18 years of age; 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.

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These qualifying elements may be established without submitting Form I-914, Supplement B, but submission of
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.

General 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.

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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. - F. The following information will help you fill out the form:
Part A. Victim Information

1. Full Name. Provide the legal name of the victim, as shown on his or her birth certificate or legal name change
document. If the victim has two last names, include both and use a hyphen (-) between the names, if appropriate.
Write the victim’s last, first and middle names in each appropriate field.
2. Other Names Used. Provide all the names the victim has used that you are aware of, including maiden name,
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).
4. Gender. Check the appropriate box.

5. 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.
Part B. Agency Information

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.
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
7. 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 18 years of age.
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.
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D. Not applicable. You do not believe this individual is a victim of trafficking.
E. Other. Attach additional sheets to explain.
8. 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.
9. Explain if the individual has expressed any fear of retaliation or revenge if they are removed from the United States.
10. Provide the dates on which the acts of trafficking occurred.
11. List the statutory citations that are or were being investigated or prosecuted.

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12. Provide the date on which the investigation or prosecution was initiated.

13. Provide the date on which the investigation or prosecution was completed.
Part D. Cooperation of 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 18 years of age or he or she is unable to cooperate with the request
due to physical or psychological trauma).
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 declaration 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 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
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 declaration. 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.
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DHS Privacy Notice
AUTHORITIES: The information requested on this application, and the associated evidence, is collected under Public
Law106-386 sections 107(e) and 1513(c) and 8 USC 1101(a)(15)(T).
PURPOSE: The primary purpose for providing the requested information on this application is to determine if you have
established eligibility for temporary immigration benefits for which you are filing. DHS uses the information you provide
to grant or deny the immigration benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number (if applicable), and any requested evidence, may delay a final decision or result in
denial of your application.

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ROUTINE USES: DHS may, where allowable under relevant confidentiality provisions, share the information you
provide on this application and any additional requested evidence with other Federal, state, local, and foreign government
agencies and authorized organizations. DHS follows approved routine uses described in the associated published system
of records notices [DHS/USCIS-001 - Alien File, Index, and National File Tracking System and DHS/USCIS-007 Benefits Information System] and published the privacy impact assessment [DHS/USCIS/PIA-016(a) Computer Linked
Application Information Management System and Associated Systems], which you can find at www.dhs.gov/privacy.
DHS may also share this information, as appropriate, for law enforcement purposes or in the interest of national security.

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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