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Form I-914
Supplement B, Declaration for Trafficking Victim
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in ink. Federal, State, Tribal, or local law enforcement
agencies should complete this form for victims under the Victims of Trafficking and
Violence Protection Act (VTVPA), Public Law 106-386, as amended.
PART 1. Victim Information
1.
OMB No. 1615-0099
Expires 02/28/2026
For USCIS Use Only
Returned
Receipt
Date
Full Legal Name
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NOT FOR
PRODUCTION
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Family Name (Last Name)
Date
Given Name (First Name)
Middle Name (if any)
Resubmitted
Date
2.
Other Names Used
Date
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 7. Additional Information.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Reloc Sent
Date
Date
Reloc Rec'd
Date
3.
Date of Birth (dd/mm/yyyy)
4.
Gender
Male
Date
Remarks
Female
Another Gender Identity
5.
Alien Registration Number (A-Number) (if any)
► A-
6.
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
(USPS ZIP Code Lookup)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Form I-914 Supp B Edition 04/01/24
ZIP Code
Page 1 of 5
Part 2. Agency Information (continued)
6.
Daytime Telephone Number
8.
Agency Type
Federal
9.
10.
11.
Case Status
On-going
State
7.
Local
Fax Number
Tribal
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Completed
Certifying Agency Category
Judge
Law Enforcement
Prosecutor
Case Number (if applicable)
12.
Other
FBI Universal Control Number (UCN) or State Identification Number (SID)
Number (if applicable)
Part 3. Statement of Claim
1.
The applicant is or has been a victim of a severe form of trafficking in persons. Specifically, they are 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 214.201.)
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. (Describe below in Item Number 2. If you need extra space to complete this section, use the space provided in
Part 7. Additional Information).
2.
Describe the victimization the applicant's claim is based on and identify the relationship between that victimization and the
crime investigated or prosecuted. Include relevant dates and any other pertinent information. If you need extra space to
complete this section, use the space provided in Part 7. Additional Information.
Form I-914 Supp B Edition 04/01/24
Page 2 of 5
Part 3. Statement of Claim (Continued)
3.
Has the applicant expressed any fear of retaliation or revenge if removed from the United States? If yes, explain. If you need
extra space to complete this section, use the space provided in Part 7. Additional Information.
4.
Provide the date(s) on which the acts of trafficking occurred.
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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)
Part 4. Cooperation of Victim
1.
The applicant:
A.
B.
2.
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.)
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.
Had not yet attained 18 years of age at the time of the trafficking.
E.
Other. (If you select this Item, provide an explanation below in Item Number 2.)
If you selected Item A., Item B., or Item E. above, provide an explanation for your selection. If you need extra space to
complete this section, use the space provided in Part 7. Additional Information.
Form I-914 Supp B Edition 04/01/24
Page 3 of 5
Part 5. Family Members Implicated In Trafficking
1.
Do you believe any of the applicant's family members have been involved in the applicant's trafficking?
No
Yes
If you answered “Yes” to Item Number 1., list the relative(s) and describe the involvement. If you need extra space to
complete this section, use the space provided in Part 7. Additional Information.
Full Name
Relationship
Involvement
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Part 6. Attestation
Based upon investigation of the facts, I certify, under penalty of perjury, that I believe that the above noted applicant 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 victim's ability to obtain nonimmigrant
status 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 they are
a victim, I will notify USCIS.
1.
Signature of Certifying Official
Date of Signature (mm/dd/yyyy)
2.
Signature of Supervisor of Certifying Official
Date of Signature (mm/dd/yyyy)
3.
Printed Name of Supervisor
Form I-914 Supp B Edition 04/01/24
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Part 7. Additional Information
If you need extra space to provide any additional information within this form, use the space below. If you need more space than what
is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print
your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which
your answer refers; and sign and date each sheet.
1.
Family Name (Last Name)
2.
A-Number ► A-
3.
A.
D.
4.
A.
D.
5.
A.
D.
6.
A.
Given Name (First Name)
Middle Name
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Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
Page Number
B.
Part Number C.
Item Number
D.
Form I-914 Supp B Edition 04/01/24
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| File Type | application/pdf |
| File Title | Form I-914, Supplement B, Declaration for Trafficking Victim |
| Author | USCIS |
| File Modified | 2024-07-08 |
| File Created | 2024-05-14 |