Form I-914B Supplement B, Declaration of Law Enforcement Officer for

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

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

For USCIS Use Only
Returned

Receipt

Date

DRAFT
Not for
Production
02/17/2021

Family Name (Last Name)
2.

USCIS
Form I-914

Given Name (First Name)

Middle Name (if any)

Resubmitted

Date

Other Names Used

Provide any other names you have 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)

Date

Given Name (First Name)

Middle Name (if any)

Date

Reloc Sent

Date
Date

Reloc Rec'd

3.

5.

Date of Birth (dd/mm/yyyy)

Gender or Sex
Male
Female

Other

Date

Remarks

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

6.

4.

Date

U.S. Social Security Number (SSN) (if any)
►

Part 2. Agency Information
1.

Name of Certifying Agency

2.

Name of Certifying Official

3.

Title of Certifying Official

4.

Division/Office of Certifying Official

5.

Agency Mailing Address

6.

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Daytime Telephone Number

Form I-914, Supplement B Edition 10/02/20

7.

ZIP Code

Fax Number

Page 1

Part 2. Agency Information (continued)
8.

Agency Type
Federal

9.
10.
11.

Case Status
On-going

State

Local

Tribal

Completed

Certifying Agency Category
Judge
Law Enforcement

Prosecutor

Case Number

12.

DRAFT
Not for
Production
02/17/2021
Other

FBI or SID Number

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.

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.
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.

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.

Form I-914, Supplement B Edition 10/02/20

Page 2

Part 3. Statement of Claim (Continued)
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.
Date (mm/dd/yyyy)

DRAFT
Not for
Production
02/17/2021

Part 4. Cooperation of Victim
1.

2.

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 the age of 18.

E.

Other, specify on attached additional sheets.

If you selected Item A. or Item B. above, provide an explanation for your selection.

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.
Full Name

Relationship

Form I-914, Supplement B Edition 10/02/20

Involvement

Page 3

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

Date of Signature (mm/dd/yyyy)

3.

Printed Name of Supervisor

DRAFT
Not for
Production
02/17/2021

Form I-914, Supplement B Edition 10/02/20

Page 4