TABLE OF CHANGES – FORM
Form I-854A, Inter-Agency Alien Witness and Informant Record
OMB Number: 1615-0046
05/17/2024
Reason for Revision: LimitedREV Project Phase: 60-Day
Legend for Proposed Text:
Expires 11/30/2024 Edition Date 04/01/2024 |
Current Page Number and Section |
Current Text |
Proposed Text |
Pages 1-3, Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information) |
[Page 1]
START HERE – Type or print in black ink.
Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.)
1. Name of Law Enforcement Agency (LEA)/Requestor
2. Requesting Agent (Special Agent in Charge, Chief of Police, etc.) Control Agent
3. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
4. Contact Information Daytime Telephone Number Fax Number E-mail Address
5. Select all applicable boxes. []As a result of providing information, the alien will be placed in danger: [] in the United States or [] abroad. [] The alien poses no danger to people or property of the United States. [] If the alien poses a danger, the danger posed bu the alien is outweighed by the assistance the alien will furnish. [] Investigation. [] Prosecution. [] United States Attorney involvement.
6. Type of Requests. (Attach legal basis for request.) [] S-5 [] S-6 [] S-7 Consular post at which visa will be sought:
NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of the request, and any bargain the LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding security precautions.
7. In the space below, provide all the requested information for the alien for whom an S classification is requested.
A. Alien’s Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name
B. Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden names, if applicable) Family Name (Last Name) Given Name (First Name) Middle Name
[Page 2]
C. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Current Location of Alien (City, State)
D. Other Information S-Visa Number
Alien Registration Number (A-Number) (if any)
Form I-94 Number
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel Document
Expiration Date for Passport or Travel Document (mm/dd/yyyy)
Date of Last Entry into the U.S. (mm/dd/yyyy)
Place of Last Entry into the U.S. (City, State)
Date of Birth (mm/dd/yyyy)
Class of Admission
Current Immigration Status
Place of Birth
Country of Origin
Country of Citizenship or Nationality
Gender Male Female
Marital Status Married Never Married Separated Divorced Widowed
Occupation
Select all documents attached: [] Form G-325 [] Form FD-258 [] Photos
8. You must provide the following information for each alien in Item Number 7.
A. Has the alien ever committed, ordered,, incited, assisted, or otherwise participated in genocide; the use, conscription, or recruitment of a child soldier; Nazi persecution; or while outside of the United States, committed torture or extrajudicial killing? If “Yes,” explain below. Yes No
[Page 3]
B. For the above named alien, I request waivers for any grounds of inadmissibility that may exist.
Below is a non-exhaustive list for possible grounds of inadmissibility. Refer to INA 212(a) for a complete list. (Specify all individual events in which the above named alien was arrested, cited, charged, indicted, convicted, fined or imprisoned, or for which the alien has committed, but did not have involvement with any law enforcement entity.)
[] Crime involving moral turpitude [212(a)(2)(A)(I)] [] International child abduction [212(a)(10)(C)] [] Multiple criminal convictions [212(a)(2)(B)] [] Engage in unlawful commercialized vice [212(a)(2)(D)] [] Involved in espionage, sabotage or laws relating to technology [212(a)(3)(A)(i)] [] Coming to overthrow the U.S. Government [212(a)(3)(A)(iii)] [] Money laundering [212(a)(2)(I)] [] Previously removed-aggravated felony [212(a)(9)(A)(i)] [] Nonimmigrant without a valid passport or visas [212(a)(7)(B)(ii)] [] Previously excluded and deported or removed [212(a)(9)(A)] [] Convicted of law pertaining to controlled substance [212(a)(2)(A)(i)(II)] [] Prostitute and/or procurer of prostitution [212(a)(2)(D)] [] Unlawful activity related to national security [212(a)(3)(A)] [] Terrorist activities [212(a)(3)(B)] [] Communist Party member [212(a)(3)(D)] [] Fraud/Misrepresentation [212(a)(6)(C)(i)] [] Immigrant without a visa [212(a)(7)] [] Human trafficking [212(a)(2)(H)] [] Ordered, incited, assisted or otherwise participated in the commission of acts of torture or extra judicial killing [212(a)(3)(E)] [] Controlled substance trafficker [212(a)(2)(C)] [] Engaged in conduct relating to severed violations of religious freedoms [212(a)(2)(G)] [] Drug abuser or addict [212(a)(1)(A)(iv)] [] Other [] No waivers are requested/needed
C. Briefly explain below each ground of inadmissibility you selected or other grounds of inadmissibility not included in the list above. If you need extra space to complete this item, attach a separate sheet of paper; type or print the alien’s 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.
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[Page 1]
START HERE – Type or print in black ink.
Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.)
1. Name of Law Enforcement Agency (LEA)/Requestor
2. Requesting Agent (Special Agent in Charge, Chief of Police, etc.) Control Agent
3. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
4. Contact Information Daytime Telephone Number Fax Number E-mail Address
5. Select all applicable boxes. []As a result of providing information, the alien will be placed in danger: [] in the United States or [] abroad. [] The alien poses no danger to people or property of the United States. [] If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish. [] Investigation. [] Prosecution. [] United States Attorney involvement.
6. Type of Requests (Attach legal basis for request.) [] S-5 [] S-6 [] S-7 Consular post at which visa will be sought:
NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of the request, and any bargain the LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding security precautions.
In the space below, provide all the requested information for the alien for whom an S classification is requested.
7.a. Alien’s Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name
7.b. Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden names, if applicable) Family Name (Last Name) Given Name (First Name) Middle Name
[Page 2]
7.c. Mailing Address Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Current Location of Alien (City, State)
7.d. Other Information S-Visa Number
Alien Registration Number (A-Number) (if any)
Form I-94 Number
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel Document
Expiration Date for Passport or Travel Document (mm/dd/yyyy)
Date of Last Entry into the U.S. (mm/dd/yyyy)
Place of Last Entry into the U.S. (City, State)
Date of Birth (mm/dd/yyyy)
Class of Admission
Current Immigration Status
Place of Birth
Country of Origin
Country of Citizenship or Nationality
Gender Male Female
Marital Status Married Never Married Separated Divorced Widowed
Occupation
Select all documents attached: [] Form G-325 [] Form FD-258 [] Photos
You must provide the following information for each alien in Item Numbers 7.a - 7.d.
8.a. Has the alien ever committed, ordered,, incited, assisted, or otherwise participated in genocide; the use, conscription, or recruitment of a child soldier; Nazi persecution; or while outside of the United States, committed torture or extrajudicial killing? If “Yes,” explain below. Yes No [fillable text]
[Page 3]
8.b. For the above named alien, I request waivers for any grounds of inadmissibility that may exist.
Below is a non-exhaustive list for possible grounds of inadmissibility. Refer to INA 212(a) for a complete list. (Specify all individual events in which the above named alien was arrested, cited, charged, indicted, convicted, fined or imprisoned, or for which the alien has committed, but did not have involvement with any law enforcement entity.)
[] Crime involving moral turpitude [212(a)(2)(A)(I)] [] International child abduction [212(a)(10)(C)] [] Multiple criminal convictions [212(a)(2)(B)] [] Engage in unlawful commercialized vice [212(a)(2)(D)] [] Involved in espionage, sabotage or laws relating to technology [212(a)(3)(A)(i)] [] Coming to overthrow the U.S. Government [212(a)(3)(A)(iii)] [] Money laundering [212(a)(2)(I)] [] Previously removed-aggravated felony [212(a)(9)(A)(i)] [] Nonimmigrant without a valid passport or visas [212(a)(7)(B)(ii)] [] Previously excluded and deported or removed [212(a)(9)(A)] [] Convicted of law pertaining to controlled substance [212(a)(2)(A)(i)(II)] [] Prostitute and/or procurer of prostitution [212(a)(2)(D)] [] Unlawful activity related to national security [212(a)(3)(A)] [] Terrorist activities [212(a)(3)(B)] [] Communist Party member [212(a)(3)(D)] [] Fraud/Misrepresentation [212(a)(6)(C)(i)] [] Immigrant without a visa [212(a)(7)] [] Human trafficking [212(a)(2)(H)] [] Ordered, incited, assisted or otherwise participated in the commission of acts of torture or extra judicial killing [212(a)(3)(E)] [] Controlled substance trafficker [212(a)(2)(C)] [] Engaged in conduct relating to severed violations of religious freedoms [212(a)(2)(G)] [] Drug abuser or addict [212(a)(1)(A)(iv)] [] Other [] No waivers are requested/needed
8.c. Briefly explain below each ground of inadmissibility you selected or other grounds of inadmissibility not included in the list above. If you need extra space to complete this item, attach a separate sheet of paper; type or print the alien’s 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.
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Pages 4-5, Part 2. Certifications |
[Page 4]
Part 2. Certifications
Alien Certification (S classification request)
I certify under penalty of perjury that I have reviewed with the LEA all the information in Part 1., disclosed all information to the best of my ability, and disclosed all reasons for which I may be inadmissible to the United States or for which I may be removed from the United States; that I shall report at least every three months my whereabouts and activities as the LEA shall require; that I understand I am subject to removal for any grounds of inadmissibility (conduct or condition) or removability not disclosed at this time or for conduct committed after admission to the United States; that I shall abide by all conditions, limitations, and restrictions imposed upon my entry; that the classification I seek is temporary and will terminate within three years; that I am restricted by the terms of my admission to very specific means by which I will be able to remain permanently in the United States; that I will pay Social Security and all applicable taxes on all employment in the United States; that I understand that such ability to remain in the United States is not guaranteed or promised by the LEA; and that I hereby waive my right to removal hearing and to contest, other than on the basis of a form for withholding of removal, any action for deportation instituted against me.
I also certify that I have read and understood all the questions and statements on this form. If I do not understand English, I further acknowledge that this has been read to me in a language I do understand. The answers I have furnished are true and correct to the best of my knowledge and belief.
Signature Date (mm/dd/yyyy) Name of Principal Alien Signature of LEA Witness Date (mm/dd/yyyy) Name of LEA Witness Title
[] Interpreter Services Used (This serves to verify the alien’s certification of interpretation.)
Signature of Interpreter Date (mm/dd/yyyy) Name of Interpreter Language Used
LEA Certification
I certify the above information is true and correct to the best of my knowledge; that I may make, have made, or will make no promises regarding the above alien’s ability to adjust status or stay permanently in the United States, other than those that comport with section 101(a)(15)(S) of the INA; that I will, upon approval of S nonimmigrant status and until adjustment of status is granted or the S nonimmigrant status expires or terminates, collect quarterly and annual reports, pursuant to 8CFR section 214(t), which detail the above alien’s whereabouts and activities, and that I will forward required information to my headquarters entity, from which point it will be forwarded to the Department of Justice, Criminal Division; that I will immediately report to my headquarters, Department of Homeland Security, U.S. Immigration and Customs Enforcement, Homeland Security Investigations, and the Department of Justice, Criminal Division if this alien fails to report quarterly or fails to comply or to cooperate with the terms and conditions of admission or if the alien commits any removable activity after the date of admission. I further certify that I assume complete law enforcement responsibility for control and continued stay in lawful status of the alien, including necessary monitoring, travel arrangements for arrival and departure, safety precautions and specified conditions of stay or departure; that I have provided a sworn declaration as to the basis of this form and checked all available databases for derogatory information on the above alien; and that I have carefully reviewed the above statements with the alien to ensure that all terms and conditions are understood.
[Page 5]
Signature of Requesting Agent Date (mm/dd/yyyy) Name of Requesting Agent Title of Requesting Agent
Signature of Headquarters (HQ) Chief of LEA
Date (mm/dd/yyyy) Name of Headquarters (HQ) Chief of LEA Title of Certifier
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 4]
Part 2. Certifications
Alien Certification (S classification request)
I certify under penalty of perjury that I have reviewed with the LEA all the information in Part 1., disclosed all information to the best of my ability, and disclosed all reasons for which I may be inadmissible to the United States or for which I may be removed from the United States; that I shall report at least every three months my whereabouts and activities as the LEA shall require; that I understand I am subject to removal for any grounds of inadmissibility (conduct or condition) or removability not disclosed at this time or for conduct committed after admission to the United States; that I shall abide by all conditions, limitations, and restrictions imposed upon my entry; that the classification I seek is temporary and will terminate within three years; that I am restricted by the terms of my admission to very specific means by which I will be able to remain permanently in the United States; that I will pay Social Security and all applicable taxes on all employment in the United States; that I understand that such ability to remain in the United States is not guaranteed or promised by the LEA; and that I hereby waive my right to removal hearing and to contest, other than on the basis of a form for withholding of removal, any action for deportation instituted against me.
I also certify that I have read and understood all the questions and statements on this form. If I do not understand English, I further acknowledge that this has been read to me in a language I do understand. The answers I have furnished are true and correct to the best of my knowledge and belief.
1. Signature Date of Signature (mm/dd/yyyy) 2. Name of Principal Alien 3. Signature of LEA Witness Date of Signature (mm/dd/yyyy) 4. Name of LEA Witness 5. Title
[] Interpreter Services Used (This serves to verify the alien’s certification of interpretation.)
6. Signature of Interpreter Date of Signature (mm/dd/yyyy) 7. Name of Interpreter 8. Language Used
LEA Certification
I certify the above information is true and correct to the best of my knowledge; that I may make, have made, or will make no promises regarding the above alien’s ability to adjust status or stay permanently in the United States, other than those that comport with section 101(a)(15)(S) of the INA; that I will, upon approval of S nonimmigrant status and until adjustment of status is granted or the S nonimmigrant status expires or terminates, collect quarterly and annual reports, pursuant to 8CFR section 214(t), which detail the above alien’s whereabouts and activities, and that I will forward required information to my headquarters entity, from which point it will be forwarded to the Department of Justice, Criminal Division; that I will immediately report to my headquarters, Department of Homeland Security, U.S. Immigration and Customs Enforcement, Homeland Security Investigations, and the Department of Justice, Criminal Division if this alien fails to report quarterly or fails to comply or to cooperate with the terms and conditions of admission or if the alien commits any removable activity after the date of admission. I further certify that I assume complete law enforcement responsibility for control and continued stay in lawful status of the alien, including necessary monitoring, travel arrangements for arrival and departure, safety precautions and specified conditions of stay or departure; that I have provided a sworn declaration as to the basis of this form and checked all available databases for derogatory information on the above alien; and that I have carefully reviewed the above statements with the alien to ensure that all terms and conditions are understood.
[Page 5]
9. Signature of Requesting Agent Date of Signature (mm/dd/yyyy) 10. Name of Requesting Agent 11. Title of Requesting Agent
12. Signature of Headquarters (HQ) Chief of LEA Date of Signature (mm/dd/yyyy) 13. Name of Headquarters (HQ) Chief of LEA 14. Title of Certifier
15. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
16. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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Pages 5-6, Part 3. For U.S. Attorney Use Only (is applicable) |
[Page 5]
Part 3. For U.S. Attorney Use Only (if applicable)
Because the alien’s presence is essential to the success of a Federal or state investigation or prosecution, the U.S. Attorney recommends the above request be granted and further certifies that there has not been and will not be any promises at all regarding the above alien’s ability to adjust status or stay permanently in the United States, other than those that comply with INA section 101(a)(15)(S).
Signature of U.S. Attorney Date (mm/dd/yyyy) Name of U.S. Attorney
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
[Page 6]
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 5]
Part 3. For U.S. Attorney Use Only (if applicable)
Because the alien’s presence is essential to the success of a Federal or state investigation or prosecution, the U.S. Attorney recommends the above request be granted and further certifies that there has not been and will not be any promises at all regarding the above alien’s ability to adjust status or stay permanently in the United States, other than those that comply with INA section 101(a)(15)(S).
1. Signature of U.S. Attorney Date of Signature (mm/dd/yyyy) 2. Name of U.S. Attorney
3. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
[Page 6]
4. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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Page 6, Part 4. For U.S. Department of State/Rewards Committee – S6 Classification use only |
[Page 6]
Part 4. For U.S. Department of State/Rewards Committee – S6 Classification use only
After checking all information, the U.S. Department of State: [] Certifies the alien is eligible to receive an award under 22 U.S.C. 2708(a) [] Certifies the alien is not eligible for such award.
Signature Date (mm/dd/yyyy) Name Title
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 6]
Part 4. For U.S. Department of State/Rewards Committee – S6 Classification use only
After checking all information, the U.S. Department of State: [] Certifies the alien is eligible to receive an award under 22 U.S.C. 2708(a) [] Certifies the alien is not eligible for such award.
1. Signature Date of Signature (mm/dd/yyyy) 2. Name 3. Title
4. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
5. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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Pages 6-7, Part 5. For Department of Justice, Criminal Division Use Only |
[Page 6]
Part 5. For Department of Justice, Criminal Division Use Only
After checking and evaluating all waivers and other information available, the Department of Justice, Criminal Division: [] Certifies that, pursuant to INA section 101(a)(15)(S) and the request of the above LEA, the above alien is recommended for the S classification requested, that the above requests for waivers of inadmissibility appear to warrant approval, that this request falls within the numerical limitation for an S vias, and that, therefore, this request is forwarded to the Director of U.S. Citizenship and Immigration Services for approval. [] Denies request.
Signature Date (mm/dd/yyyy) Name Title
[Page7]
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 6]
Part 5. For Department of Justice, Criminal Division Use Only
After checking and evaluating all waivers and other information available, the Department of Justice, Criminal Division: [] Certifies that, pursuant to INA section 101(a)(15)(S) and the request of the above LEA, the above alien is recommended for the S classification requested, that the above requests for waivers of inadmissibility appear to warrant approval, that this request falls within the numerical limitation for an S vias, and that, therefore, this request is forwarded to the Director of U.S. Citizenship and Immigration Services for approval. [] Denies request.
1. Signature Date of Signature (mm/dd/yyyy) 2. Name 3. Title
[Page7]
4. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
5. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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Page 7, For U.S. Citizenship and Immigration Services Use Only |
[Page 7]
Part 6. For U.S. Citizenship and Immigration Services Use Only
LEA Request: [] Granted [] Forwarded to DOS/Visa Office (VO) [] Denied
Signature Date (mm/dd/yyyy) Name Title
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 7]
Part 6. For U.S. Citizenship and Immigration Services Use Only
LEA Request: [] Granted [] Forwarded to DOS/Visa Office (VO) [] Denied
1. Signature Date of Signature (mm/dd/yyyy) 2. Name 3. Title
4. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
5. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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Page 8, For Department of State/Visa Office Use Only |
[Page 8]
Part 7. For Department of State/Visa Office Use Only
[] Forwarded to Consul by VO for Visa Approval [] Not Forwarded
Signature Date (mm/dd/yyyy) Name Title
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
[] Visa Granted [] Visa Denied
Signature Date (mm/dd/yyyy) Name Title
Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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[Page 8]
Part 7. For Department of State/Visa Office Use Only
[] Forwarded to Consul by VO for Visa Approval [] Not Forwarded
1. Signature Date of Signature (mm/dd/yyyy) 2. Name 3. Title
4. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
5. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
[] Visa Granted [] Visa Denied
6. Signature Date of Signature (mm/dd/yyyy) 7. Name 8. Title
9. Office Name and Mailing Address Office Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code
10. Office Contact Information Daytime Telephone Number Fax Number E-mail Address
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |