Form 1 Certificaiton Instrument

OMB Control Number: 0970-0454
Expiration Date: 05/31/2018

Information Requested for Foreign Adult Human Trafficking Victims Seeking HHS Certification
HHS provides letters of certification and eligibility to foreign national victims of severe forms of
human trafficking under the authority of the Trafficking Victims Protection Act of 2000, as amended,
22 U.S.C. Section 7105(b)(1)(C) and (E). This form can be used to provide information to obtain a
Certification Letter from HHS. Certification is required for foreign adult victims of human trafficking in
the United States to apply for federally funded benefits and services.
Do not use this form for minors with Continued Presence or a T Nonimmigrant visa. To obtain
a HHS Eligibility Letter for a foreign trafficking victim under 18 years of age, contact
ChildTrafficking@acf.hhs.gov for assistance.
This form is not an application. Use of this form is optional. If you do not wish to use this form
and would like to obtain a HHS Certification Letter, please contact a HHS Trafficking Specialist at
866-401-5510 or email Trafficking@acf.hhs.gov.

INSTRUCTIONS AND OVERVIEW FOR CERTIFICATION PROCESS
1. Please read entire form before completing it.
2. Fill out all sections that apply to the person who was trafficked.
3. Send the completed form and supporting documentation (e.g. T-1 Nonimmigrant Status
(T-1 Visa)) to Trafficking@acf.hhs.gov with the subject line as "HHS Certification
Request."
4. To further protect the confidentiality of the communication, you can transmit the form as a
password-protected PDF and send the password in a separate email to
Trafficking@acf.hhs.gov.
To protect privacy,do not include personal information (e.g., name, alien number) about the victim
in the subject line or body of the emails.
HHS will issue a Certification Letter after receiving the information provided in this form and the
supporting document. If HHS needs additional information, a HHS representative will contact you.
Questions? Contact a HHS Trafficking Specialist at 866-401-5510 during regular business hours,
Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time, or email Trafficking@acf.hhs.gov.
The National Human Trafficking Hotline at 1-888-373-7888 is available 24 hours a day, 7 days a
week for technical assistance and service referrals.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average .25 hours per response, including the
time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

Section 1: Case Management/Requestor Information
Please complete Section 1 if you are the victim's case manager. If not, then go to Section 2.
Case Manager's/Requestor's Name
Last

Middle

First

Title
Name of Agency/Organization

Phone

Extension

Email
Address
State

City

Zip Code

I agree to receive the HHS Certification Letter and to provide it to the victim without delay upon
receipt.

Section 2: Referral for Case Management
HHS funds the Trafficking Victim Assistance Program (TVAP). TVAP provides case management
services, including referrals and emergency assistance, for foreign national persons who have been
trafficked and are seeking HHS Certification. It can also assist recipients of HHS Certification and
certain family members with accessing federal and state benefits and services.
Please indicate the victim's preference regarding access to TVAP services:
Yes, I would like to be connected with a TVAP provider.
No, I do not want to be connected with a TVAP provider at this time.
If "yes" is selected above, please provide the ciy and state where the victim resides so that a case
manager can be identified who is located near the victim.
State

City

Zip Code

Please indicate to whom the Certification Letter should be mailed and the recipient's mailing address:
Victim

Case Manager

Address
City

State

Zip Code

Please describe below any emergency needs (e.g., housing, medical care, or food) of the victim:

Section 3: Victim Information
Victim's Initials

Alien Number

Country of Origin

Primary Language

Date of Birth (MM/DD/YYYY)
Sex of Victim

Type of Trafficking Experienced

Male
Female

Sex Trafficking
Labor Trafficking
Both

Please submit with this form one of the following documents:
Continued Presence that has not been rescinded,
Current T-1 Nonimmigrant Status, or
Bona Fide T-1 Visa that has not been denied
Preferred Certification Effective Date (MM/DD/YYYY):
(Do not provide a date later than two weeks from the date of submission of this form.)

Important Notice Regarding Information Sharing
Please read the following information. If this form is not in the victim’s primary language or if the
victim is unable to read or understand the form, the representative should read and explain the form
to them in his or her primary language or use a qualified interpreter to do so. This notification is
intended to inform the victim of how the information provided will be used by HHS.
The Department of Health and Human Services (HHS) is a federal government agency that is
responsible for identifying and assisting potential victims of human trafficking. HHS provides letters
of certification and eligibility to foreign national victims of severe forms of human trafficking, making
them eligible to receive federal and state benefits to the same extent as a refugee.
HHS provides letters of certification and eligibility to foreign national victims of severe forms of
human trafficking under the authority of the Trafficking Victims Protection Act of 2000 (TVPA), as
amended 22 U.S.C. Section 7105(b)(1)(C) and (E).
HHS will use the information collected in the HHS Certification form for one or more of the following
purposes, and to comply with the TVPA:
1. To coordinate the delivery of a HHS Certification Letter to a foreign adult present in the United
States who has been subjected to a severe form of trafficking in persons;
2. To refer a foreign adult victim of trafficking in the United States to a case manager to assist
the person in obtaining needed benefits and services; and
3. To report aggregated data on trafficking victims assisted by HHS in federal reports and to the
public.
HHS will not share any personally identifiable information such as the victim's name or alien number
for reports or publicly available data sets. The information contained in the form may be disclosed for
a legitimate law enforcement purpose, including in response to a discovery request or otherwise in
the course of criminal or civil litigation. If you have any questions about this form, you may contact a
HHS Trafficking Specialist at 866-401-5510 or Trafficking@acf.hhs.gov.
The victim gives consent to share the information contained in the HHS Certification form as
necessary for processing the request for certification and for reporting purposes. The victim
acknowledges that they have been notified that their information will be used in federal reports or
data that is available to the public in a way that does not disclose personally identifiable information
and is generally reported in aggregate data.
By signing this form, you acknowledge that the victim has been informed that the information
provided in this form might be shared with other federal agencies as part of aggregated data
reporting, and with public and nongovernmental organizations for the purpose of confirming eligibility
for benefits, or for referral to a TVAP provider.

Requestor’s Signature : ___________________________________________________
Date: _____________________________