I-914b Frm Toc

I914SupB-006-FRM-TOC-REV-30Day-02172021.docx

Application for T Nonimmigrant Status; Application for Immediate Family Member of T-1 Recipient; & Declaration of Law Enforcement Officer for Victim of Trafficking in Persons

I-914B FRM TOC

OMB: 1615-0099

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TABLE OF CHANGES – FORM

Supplement B to Form I-914, Declaration of Law Enforcement Office for Victim of Trafficking in Persons

OMB Number: 1615-0099

02/17/2021


Reason for Revision: Revision

Project Phase: 60 Day


Legend for Proposed Text:

  • Black font = Current text

  • Red font = Changes


Expires 04/30/2021

Edition Date 10/02/2020



Current Page Number and Section

Current Text

Proposed Text

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



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