Page 1,
PART
A. Victim Information
|
[Page 1]
START
HERE
-
Type
or
print
in
blank
ink.
This
form
should
be
completed
by
Federal,
State,
or
local
law
enforcement
authorities
for
victims
under
the
Victims
of
Trafficking
and
Violence
Protection
Act,
Public
Law
106-386,
as amended.
PART
A. Victim Information
Family
Name
(Last
Name)
Given
Name
(First
Name)
Middle
Name
Other
Names
Used
(include
maiden
name/nickname)
Date
of Birth
(mm/dd/yyyy)
Gender
Male
Female
A
#
(if
known)
Social
Security
#
(if
known)
|
[Page 1]
START
HERE
-
Type
or
print
in
ink.
This
form
should
be
completed
by
Federal,
state,
local,
or tribal
law
enforcement
agencies
for
victims
under
the
Victims
of
Trafficking
and
Violence
Protection
Act
(VTVPA),
Public
Law
106-386,
as amended.
Part
1. Victim
Information
1.
Full
Legal Name
Family
Name
(Last
Name)
Given
Name
(First
Name)
Middle
Name
(if any)
2.
Other
Names
Used
Provide
any other names the victim has used since birth, including
aliases, maiden names, and nicknames. If you need extra space to
complete this section, use the space provided in Part
9. Additional Information.
Family
Name (Last Name) [x2]
Given
Name (First Name)
Middle
Name (if any)
3.
Date
of Birth
(mm/dd/yyyy)
4.
Gender
or Sex
Male
Female
Other
5.
Alien
Registration Number (A-Number) (if any)
6.
U.S.
Social
Security Number
(SSN) (if any)
|
Page 1,
PART
B. Agency Information
|
[Page 1]
PART
B. Agency Information
Name
of Certifying
Agency
Name
of Certifying
Official
Title
and
Division/Office
of
Certifying
Official
Agency
Address
-
Street
Number
and
Name
Suite
#
City
State/Province
Zip/Postal
Code
Daytime
Phone
#
(area
code
and/or
extension)
Fax
#
(with
area
code)
Agency
Type
Federal
State
Local
Case
Status
On-going
Completed
Local
Certifying
Agency
Category
Judge
Law
Enforcement
Prosecutor
Other
Case
Number
FBI
or
SID
Number
(if
applicable)
|
[Page 1]
Part
2. Agency
Information
1.
Name
of Certifying
Agency
2.
Name
of Certifying
Official
[Page
2]
3.
Title
of
Certifying
Official
4.
Division/Office of Certifying Official
5.
Agency
Mailing
Address
Street
Number and Name
Apt./Ste./Flr.
[Number]
City or
Town
State
ZIP
Code
6.
Daytime
Telephone
Number
7.
Fax
Number
8.
Agency
Type
Federal
State
Local
Tribal
9.
Case
Status
On-going
Completed
10.
Certifying
Agency
Category
Judge
Law
Enforcement
Prosecutor
Other
11.
Case
Number
12.
FBI
or
SID
Number
|
Pages 1-2,
PART
C. Statement of Claim
|
[Page 1]
PART
C. Statement of Claim
1.
The
applicant
is
or
has been
a
victim
of
a
severe
form
of
trafficking
in
persons.
Specifically,
he
or
she is
a
victim
of:
(Check
all
that
apply.
Base
your
analysis
on
the
practices
to
which
the
victim
was
subjected
rather
than
on
the
specific
violations
charged,
the
counts
on
which
convictions
were
obtained,
or
whether
any
prosecution
resulted
in
convictions.
Note
that
the
definitions
that
control
this
analysis
are
not
the
elements
of
criminal
offenses,
but
are
those
set
forth
at
8
CFR
214.11(a).)
Sex
trafficking
in
which
a
commercial
sex
act
was
induced
by
force,
fraud,
or
coercion.
Sex
trafficking
means
the
recruitment,
harboring,
transportation,
provision,
or
obtaining
of
a
person
for the
purpose
of a
commercial
sex
act.
Sex
trafficking
and
the
victim
is
under
the
age
of
18.
[Page
2]
The
recruitment,
harboring,
transportation,
provision,
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.
Not
applicable.
Other,
specify
on
attached
additional
sheets.
2.
Please
describe
the
victimization
upon
which
the
applicant's
claim
is
based
and
identify
the
relationship
between
that
victimization
and
the
crime
under
investigation/prosecution.
Attach
the
results
of
any
name
or
database
inquiry
performed
in
the
investigation
of
the
case,
as
well
as
any
relevant
reports
and
findings.
Include
relevant
dates,
etc.
Attach
additional
sheets,
if
necessary.
3.
Has
the
applicant
expressed
any
fear
of
retaliation
or
revenge
if
removed
from
the
United
States?
If
yes, explain.
Attach
additional
sheets,
if
necessary.
4.
Provide
the
date(s)
on
which
the
acts
of
trafficking
occurred.
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
5.
List
the
statutory
citation(s)
for
the
acts
of
trafficking
being
investigated
or
prosecuted,
or
that
were
investigated
or
prosecuted.
6.
Provide
the
date
on
which
the
investigation
or
prosecution
was
initiated.
Date
(mm/dd/yyyy)
7.
Provide
the
date
on
which
the
investigation
or
prosecution
was
completed
(if
any).
Date
(mm/dd/yyyy)
|
[Page 2]
Part
3. Statement
of Claim
1.
The
applicant
is
or
has been
a
victim
of
a
severe
form
of
trafficking
in
persons.
Specifically,
he
or
she is
a
victim
of:
(Select
all
that
apply.
Base
your
analysis
on
the
victimization
the applicant experienced
rather than
on
the
specific
violations
charged,
the
counts
on
which
convictions
were
obtained,
or
whether
any
prosecution
resulted
in
convictions.
Note
that
the
definitions
that
control
this
analysis
are
not
the
elements
of
criminal
offenses,
but
are
those
set
forth
at
8
CFR
214.11(a).)
Sex
trafficking
in
which
a
commercial
sex
act
was
induced
by
force,
fraud,
or
coercion.
Sex
trafficking
means
the
recruitment,
harboring,
transportation,
provision,
obtaining,
patronizing, or soliciting
of
a
person
for the
purpose
of a
commercial
sex
act.
Sex
trafficking
and
the
victim
is
under
18
years of age.
[Page
2]
The
recruitment,
harboring,
transportation,
provision,
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.
[deleted]
Other,
specify
on
attached
additional
sheets.
2.
Please
describe
the
victimization
the
applicant's
claim
is
based
on
and
identify
the
relationship
between
that
victimization
and
the
crime
investigated or prosecuted. Attach the
results
of
any
name
or
database
inquiry
performed
in
the
investigation
of
the
case,
as
well
as
any
relevant
reports
and
findings.
Include
relevant
dates,
etc.
Attach
additional
sheets,
if
necessary.
[Page
3]
3.
Has
the
applicant
expressed
any
fear
of
retaliation
or
revenge
if
removed
from
the
United
States?
If
yes, explain.
Attach
additional
sheets,
if
necessary.
4.
Provide
the
date(s)
on
which
the
acts
of
trafficking
occurred.
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
5.
List
the
statutory
citation(s)
for
the
acts
of
trafficking
being
investigated
or
prosecuted,
or
that
were
investigated
or
prosecuted.
6.
Provide
the
date
on
which
the
investigation
or
prosecution
was
initiated.
Date
(mm/dd/yyyy)
7.
Provide
the
date
on
which
the
investigation
or
prosecution
was
completed
(if
any).
Date
(mm/dd/yyyy)
|
Page 3,
PART
D. Cooperation of Victim (Attach
additional sheets, if necessary)
|
[Page
3]
PART
D.
Cooperation of Victim
The
applicant:
Has
complied
with
requests
for
assistance
in
the
investigation/prosecution
of
the
crime
of
trafficking.
(Explain
below.)
Has
failed
to
comply
with
requests
to
assist
in
the
investigation/prosecution
of
the
crime
of
trafficking.
(Explain
below.)
Has
not
been
requested
to
assist
in
the
investigation/prosecution
of
any
crime
of
trafficking.
Has
not
yet
attained
the
age
of
18.
Other,
specify
on
attached
additional
sheets.
|
[Page
3]
Part
4.
Cooperation
of Victim
1.
The
applicant:
A.
Has
complied with requests for assistance in the
investigation/prosecution of the crime of trafficking. (If
you select Item
A.,
provide an explanation below in Item
Number 2.)
B.
Has
failed to comply with requests to assist in the
investigation/prosecution of the crime of trafficking. (If
you select Item
B.,
provide an explanation below in Item
Number 2.)
C.
Has
not been requested to assist in the investigation/prosecution of
any crime of trafficking.
D.
Has
not yet attained 18
years of age.
E.
Other,
specify on attached additional sheets.
2.
If you selected Item
A.
or Item
B.
above, provide an explanation for your selection.
|
Page 3,
Part
E. Family Members Implicated In Trafficking
|
[Page
3]
PART
E. Family Members Implicated in Trafficking
Are
any of the applicant's family members believed to have been
involved in his or her trafficking to the United States?
Yes
No
If
"Yes," list the relative(s) and describe the
involvement. Attach additional sheets if necessary.
[Table,
3 columns, 4 rows]
Full
Name
Relationship
Involvement
|
[Page
4]
Part
5. Family
Members Implicated in Trafficking
1.
Are
any of the applicant's family members believed to have been
involved in his or her trafficking to the United States?
Yes
No
If
you
answered “Yes” to Item
Number 1.,
list
the relative(s) and describe the involvement. Attach additional
sheets if necessary.
[Table,
3 columns, 4 rows]
Full
Name
Relationship
Involvement
|
Page 3,
PART
F. Attestation
|
[Page
3]
PART
F.
Attestation
Based
upon
investigation
of
the
facts,
I
certify,
under
penalty
of
perjury,
that
the
above
noted
individual
is
or
has been
a
victim
of
a severe
form
of
trafficking
in
persons
as defined
by
the
VTVPA.
I certify
that
the
above
information
is
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,
based
upon
this
certification.
I
further
certify
that
if
the
victim
unreasonably
refuses
to
assist
in
the
investigation
or
prosecution
of
the
acts
of
trafficking
of
which
he/she
is
a
victim,
I
will
notify
USCIS.
Signature
of
Law Enforcement
Officer
(identified
in
Part
B)
(sign
in
ink)
Date
(mm/dd/yyyy)
Signature
of
Supervisor
of
Certifying
Officer
(sign
in
ink)
Date
(mm/dd/yyyy)
Printed
Name
of Supervisor
|
[Page
4]
Part
6. Attestation
Based
upon
investigation
of
the
facts,
I
certify,
under
penalty
of
perjury,
that
the
above
noted
individual
is
or
has been
a
victim
of
a severe
form
of
trafficking
in
persons
as defined
by
the
VTVPA.
I certify
that
the
above
information
is
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
refuses
to comply with reasonable requests for assistance
in
the
investigation
or
prosecution
of
the
acts
of
trafficking
of
which
he/she
is
a
victim,
I
will
notify
USCIS.
1.
Signature
of
Law Enforcement
Officer
(identified
in
Part
2.)
Date
of
Signature (mm/dd/yyyy)
2.
Signature
of
Supervisor
of
Certifying
Officer
[delete]
Date
of
Signature (mm/dd/yyyy)
3.
Printed
Name
of Supervisor
|