Fillable Form I-854A: Inter-Agency Alien Witness and Informant Record (USCIS)

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Form I-854A: Inter-Agency Alien Witness and Informant Record (USCIS)

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The Form I-854A: Inter-Agency Alien Witness and Informant Record (USCIS) form is 8 pages long and contains:

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-854A Edition 11/08/19 Page 1 of 8
USCIS
Form I-854A
OMB No. 1615-0046
Expires 11/30/2021
Inter-Agency Alien Witness
and Informant Record
Department of Homeland Security
U.S. Citizenship and Immigration Services
Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.)
START HERE - Type or print in black ink.
2. Control Agent
E-mail Address
3. Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Daytime Telephone Number
4. Contact Information
Fax Number
5. Select all applicable boxes.
6. Type of Requests. (Attach legal basis for request.)
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.
As a result of providing information, the alien will be placed in danger:
abroad. in the United States or
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.
S-5
S-6
Consular post at which visa will be sought:S-7
7.
Family Name (Last Name) Given Name (First Name) Middle Name
A. Alien's Current Legal Name (do not provide a nickname)
B.
Family Name (Last Name) Given Name (First Name) Middle Name
1. Name of Law Enforcement Agency (LEA)/Requestor
Requesting Agent (Special Agent in Charge, Chief of Police, etc.)
In the space below, provide all the requested information for the alien for whom an S classification is requested.
Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable)
The alien poses no danger to people or property of the United States.
Form I-854A Edition 11/08/19 Page 2 of 8
Place of Birth
Marital Status
Divorced
Married
Widowed
Never Married
Separated
Female
Gender
Male
Class of Admission
Date of Birth (mm/dd/yyyy)
Current Immigration Status
Alien Registration Number
(A-Number) (if any) Form I-94 Number
Date of Last Entry into the U.S.
(mm/dd/yyyy)
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel
Document
Expiration Date for Passport or
Travel Document (mm/dd/yyyy)
Place of Last Entry into the U.S. (City, State)
Country of Origin
Country of Citizenship or Nationality
Occupation Select all documents attached:
Form G-325
Form FD-258 Photos
Part 1. To be completed by Law Enforcement Agencies (continued)
Street Number and Name
Flr.Ste.Apt.
City or Town State ZIP Code Current Location of Alien (City, State)
S-Visa Number
Mailing AddressC.
Other InformationD.
8.
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
A.
You must provide the following information for each alien named in Item Number 7.
Form I-854A Edition 11/08/19 Page 3 of 8
B.
International child abduction [212(a)(10)(C)]
Engage in unlawful commercialized vice
[212(a)(2)(D)]
Coming to overthrow the U.S. Government
[212(a)(3)(A)(iii)]
Crime involving moral turpitude [212(a)(2)(A)(I)]
Multiple criminal convictions [212(a)(2)(B)]
Involved in espionage, sabotage or laws relating to
technology [212(a)(3)(A)(i)]
Money laundering [212(a)(2)(I)]
Engaged in conduct relating to severed violations of
religious freedoms [212(a)(2)(G)]
Previously removed-aggravated felony
[212(a)(9)(A)(i)]
Nonimmigrant without a valid passport or visas
[212(a)(7)(B)(ii)]
Alien smuggler [212(a)(6)(E)]
Drug abuser or addict [212(a)(1)(A)(iv)]
Previously excluded and deported or removed
[212(a)(9)(A)]
Convicted of law pertaining to controlled substance
[212(a)(2)(A)(i)(II)]
Controlled substance trafficker [212(a)(2)(C)]
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)]
Other
No waivers are requested/needed
Unlawful activity related to national security
[212(a)(3)(A)]
Communist Party member [212(a)(3)(D)]
Terrorist activities [212(a)(3)(B)]
Prostitute and/or procurer of prostitution [212(a)(2)(D)]
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.
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.)
Form I-854A Edition 11/08/19 Page 4 of 8
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 a removal hearing and to contest,
other than on the basis of a form for withholding of removal, any action for deportation instituted against me.
Part 2. Certifications
Alien Certification (S classification request)
I also certify that I have read and understand 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.
Name of Principal Alien
Signature Date (mm/dd/yyyy)
Name of LEA Witness
Date (mm/dd/yyyy)
Title
Signature of LEA Witness
Name of Interpreter
Date (mm/dd/yyyy)
Language Used
Signature of Interpreter
LEA Certification
I certify the above information is true and correct to the best of my knowledge; that I may make, have made, and 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 8 CFR section 214.2(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.
Interpreter Services Used (This serves to verify the alien's certification of interpretation.)
Form I-854A Edition 11/08/19 Page 5 of 8
Part 2. Certifications (continued)
Signature of Requesting Agent
Name of Requesting Agent
Date (mm/dd/yyyy)
Title of Requesting Agent
Signature of Headquarters (HQ) Chief of LEA
Name of Headquarters (HQ) Chief of LEA
Date (mm/dd/yyyy)
Title of Certifier
Office Name and Mailing Address
City or Town State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
E-mail Address
Daytime Telephone Number Fax Number
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).
Name of U.S. Attorney
Signature of U.S. Attorney
Date (mm/dd/yyyy)
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Form I-854A Edition 11/08/19 Page 6 of 8
Office Contact Information
E-mail Address
Daytime Telephone Number Fax Number
Part 4. For U.S. Department of State/Rewards Committee - S6 Classification use only
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.
After checking all information, the U.S. Department of State:
Part 3. For United States Attorney Use Only (if applicable) (continued)
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
E-mail Address
Daytime Telephone Number Fax Number
Date (mm/dd/yyyy)
Signature
Name
Title
Part 5. For Department of Justice, Criminal Division Use Only
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 visa, and that, therefore, this request is forwarded to the Director of U.S. Citizenship and
Immigration Services for approval.
After checking and evaluating all waivers and other information available, the Department of Justice, Criminal Division:
Denies request.
Name
Date (mm/dd/yyyy)
Title
Signature
Form I-854A Edition 11/08/19 Page 7 of 8
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
Part 5. For Department of Justice, Criminal Division Use Only (continued)
Part 6. For U.S. Citizenship and Immigration Services Use Only
LEA Request: Granted Forwarded to DOS/Visa Office (VO) Denied
Office Name and Mailing Address
City or Town State
ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Name
Date (mm/dd/yyyy)
Title
Signature
Office Contact Information
E-mail Address Daytime Telephone Number Fax Number
E-mail Address
Daytime Telephone Number Fax Number
Form I-854A Edition 11/08/19 Page 8 of 8
Part 7. For Department of State/Visa Office Use Only
Forwarded to Consul by VO for Visa Approval Not Forwarded
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Name
Date (mm/dd/yyyy)
Title
Signature
Office Contact Information
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
Visa Granted Visa Denied
Name
Date (mm/dd/yyyy)
Title
Signature
E-mail Address Daytime Telephone Number Fax Number
E-mail Address
Daytime Telephone Number Fax Number
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Form I-854A: Inter-Agency Alien Witness and Informant Record (USCIS)

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Completed 20 September 2021

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