Page 1,
|
[Page 1]
For USCIS Use Only
Returned
Date
Date
Resubmitted
Date
Date
Reloc Sent
Date
Date
Reloc Rec’d
Date
Date
Receipt
Remarks
START
HERE
-
Type
or
print
in
ink.
This
form
should
be
completed
by
Federal,
state,
local,
or tribal
law
enforcement
agencies
for
victims
under
the
Victims
of
Trafficking
and
Violence
Protection
Act
(VTVPA),
Public
Law
106-386,
as amended.
|
[Page 1]
For USCIS Use Only
Returned
Date
Date
Resubmitted
Date
Date
Reloc Sent
Date
Date
Reloc Rec’d
Date
Date
Receipt
Remarks
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.
|
Page 1,
Part
1. Victim Information
|
[Page 1]
Part
1. Victim Information
1.
Full
Legal Name
Family
Name
(Last
Name)
Given
Name
(First
Name)
Middle
Name
(if any)
2.
Other
Names
Used
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 9.
Additional Information.
Family
Name (Last Name) [x2]
Given
Name (First Name)
Middle
Name (if any)
3.
Date
of Birth
(mm/dd/yyyy)
4.
Gender
or Sex
Male
Female
Other
5.
Alien
Registration Number (A-Number) (if any)
6.
U.S.
Social Security Number (SSN) (if any)
|
[Page
1]
Part
1. Victim Information
1.
Full
Legal Name
Family
Name
(Last
Name)
Given
Name
(First
Name)
Middle
Name
(if any)
2.
Other
Names
Used
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) [x2]
Given
Name (First Name)
Middle
Name (if any)
3.
Date
of Birth
(mm/dd/yyyy)
4.
Gender
Male
Female
Another
Gender Identity
5.
Alien
Registration Number (A-Number) (if any)
6.
U.S.
Social Security Number (SSN) (if any)
|
Pages 2-3,
Part
3. Statement of Claim
|
[Page 2]
Part
3. 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:
(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
214.11(a).)
Sex
trafficking
in
which
a
commercial
sex
act
was
induced
by
force,
fraud,
or
coercion.
Sex
trafficking
means
the
recruitment,
harboring,
transportation,
provision,
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,
specify
on
attached
additional
sheets.
2.
Please
describe
the
victimization
the
applicant's
claim
is
based
on
and
identify
the
relationship
between
that
victimization
and
the
crime
investigated or prosecuted. 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.
…
|
[Page 2]
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.
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.
…
|
Page
3,
Part
4.
Cooperation of Victim
|
[Page
3]
Part
4.
Cooperation of Victim
…
D.
Has not yet attained 18 years of age.
E.
Other, specify on attached additional sheets.
2.
If you selected Item
A.
or Item
B.
above, provide an explanation for your selection.
|
[Page 3]
Part
4.
Cooperation of Victim
…
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.)
2.
If you selected Item
A.
or Item
B.
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.
|
Page
3,
Part
5. Family Members Implicated in Trafficking
|
[Page
3]
Part
5. Family Members Implicated in Trafficking
1.
Are any of the applicant's family members believed to have been
involved in his or her trafficking to the United States?
Yes
No
If
you answered “Yes” to Item
Number 1.,
list the relative(s) and describe the involvement. Attach
additional sheets if necessary.
[Table,
3 columns, 4 rows]
Full
Name
Relationship
Involvement
|
[Page 3]
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?
Yes
No
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.
[Table,
3 columns, 4 rows]
Full
Name
Relationship
Involvement
|
Page
4,
Part
6. Attestation
|
[Page
4]
Part
6. 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
(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
he/she
is
a
victim,
I
will
notify
USCIS.
1.
Signature
of
Law Enforcement
Officer
(identified
in
Part
2.)
Date
of Signature (mm/dd/yyyy)
2.
Signature
of
Supervisor
of
Certifying
Officer
Date
of Signature (mm/dd/yyyy)
3.
Printed
Name
of Supervisor
|
[Page 4]
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
(identified
in
Part
2.)
Date
of Signature (mm/dd/yyyy)
2.
Signature
of
Supervisor
of
Certifying
Official
Date
of Signature (mm/dd/yyyy)
3.
Printed
Name
of Supervisor
|