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 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.

OMB No. 1615-0099
Expires 07/31/2016

For USCIS Use Only
Returned

Receipt

Date

PART A. Victim Information
Family Name (Last Name)

USCIS
Form I-914

Given Name (First Name)

Middle Name (if any)

Date
Resubmitted

DRAFT
Not for
Reproduction
T-Rule
01/09/2017

Other Names Used (include maiden name/nickname)
Date of Birth (mm/dd/yyyy)

Date
Date

Gender

Male

A # (if known)

Female

Social Security # (if known)

Reloc Sent

Date
Date

Part B.

Agency Information

Reloc Rec'd

Name of Certifying Agency

Date

Name of Certifying Official

Title and Division/Office of Certifying Official

Date

Remarks

Agency Address - Street Number and Name
City

Suite #

State/Province

Daytime Phone # (area code and/or extension)

Agency Type
Federal

Case Status
On-going

State

Local

Completed

Local

Certifying Agency Category
Judge
Law Enforcement
Case Number

Zip/Postal Code

Fax # (with area code)

Prosecutor

Other

FBI # or SID # (if applicable)

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.
Form I-914, Supplement B 07/29/14 Y

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Part C. Statement of Claim

(Continued)

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.

DRAFT
Not for
Reproduction
T-Rule
01/09/2017

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)

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Part D. Cooperation of Victim (Attach additional sheets, if necessary)
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.

DRAFT
Not for
Reproduction
T-Rule
01/09/2017

Part E. Family Members Implicated In Trafficking
Yes

No

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

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)

Date (mm/dd/yyyy)

Signature of Supervisor of Certifying Officer

Date (mm/dd/yyyy)

Printed Name of Supervisor

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