TABLE OF CHANGES – FORM
FORM I-914 SUPP B
12-10-2008
LOCATION |
CURRENT VERSION |
PROPOSED VERSION |
Page 1 – Instructions to Certifying Official |
INSTRUCTIONS TO CERTIFYING OFFICER: This applicant is applying for immigration benefits based upon a claim of having been a victim of a severe form of trafficking in persons. Please complete the form below based upon your knowledge of the case, including evidence developed by other law enforcement officers investigating the case.
In order to be granted immigration benefits, the applicant must demonstrate that he or she is present in the United States as a result of being a victim of a severe form of trafficking in persons. Unless the applicant is less than 18 years old, the applicant must also demonstrate that he or she is cooperating with law enforcement in the investigation and prosecution of the trafficking crime of which he or she was a victim.
To be completed by Federal Law Enforcement Officers for victims under the Victims of Trafficking and Violence Protection Act, Public Law 106-386. |
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. |
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For USCIS Use Only
Returned Receipt
Date
Date
Resubmitted
Date
Date
Reloc Sent
Date
Date
Reloc Rec’d
Date
Date
Remarks |
Page 1 – Part A |
General Information.
Name of Government Agency:
U.S. Citizenship and Immigration Services, DHS
Civil Rights Division, DOJ
U.S. Marshal’s Service, DOJ
Federal Bureau of Investigation, DOJ
Criminal Division, DOJ
U.S. Attorney’s Office, DOJ
Diplomatic Security, DOS
Other
Date (mm/dd/yyyy)
Address of Agency/Official
Name and Title of Certifying Officer or Official
City
State
ZIP Code
Phone No.
Fax No.
Victim’s Name
Other Names Used
Gender
Male Female
Date of Birth (mm/dd/yyyy)
Date of Crime (mm/dd/yyyy)
Charges
Case No.
Date Initiated (mm/dd/yyyy)
Case Status
On-going Completed N/A
Date Completed (mm/dd/yyyy)
FBI Identification No., if any
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Part A. Victim Information
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
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 |
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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 # (if applicable) |
Page 1 – Part B
Add new questions |
Part B. Statement of Claim.
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Part C. Statement of Claim
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)
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Page 2 – Part C |
Part C. Cooperation of Victim. (Attach additional sheets, if necessary) |
Part D. Cooperation of Victim (Attach additional sheets, if necessary)
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Page 2 – Part D |
Part D. Family Members.
Are any of the applicant's relatives believed to have been involved in his or her trafficking to the United States? If Yes, list the relatives and describe that relative's involvement in the applicant's trafficking. |
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? If “Yes,” list the relative(s) and describe the involvement. Attach additional sheets, if necessary.
Full Name
Relationship
Involvement
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Page 2 – Part E |
Part E. 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 the U.S. Citizenship and Immigration Services, based upon this certification.
(Signature of Law Enforcement Officer identified in Box A above) |
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 the 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) |
File Type | application/msword |
File Title | LOCATION |
Author | jdimpera |
Last Modified By | jdimpera |
File Modified | 2008-12-11 |
File Created | 2008-12-09 |