Supplement B, Delaration of Law Enforcement Officer for
Victim of Trafficking in Persons
Department of Homeland Security
U.S. Citizenship and Immigration Services
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.
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.
Local
Agency Address - Street Number and Name
Middle Name (if any)Given Name (First Name)Family Name (Last Name)
Other Names Used (include maiden name/nickname)
Name of Certifying Official Title and Division/Office of Certifying Official
Social Security # (if known)
Suite Number
City State/Province Zip/Postal Code
Daytime Phone # (area code and/or extension) Fax # (with area code)
Part B. Agency Information
PART A. Victim Information
Male
Gender
Female
Date of Birth (mm/dd/yyyy)
Name of Certifying Agency
Agency Type
StateFederal
Case Status
CompletedOn-going Local
Certifying Agency Category
Law EnforcementJudge Prosecutor Other
FBI or SID Number (if applicable)Case Number
A # (if known)
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).)
Part C. Statement of Claim
Sex trafficking and the victim is under the age of 18.
For USCIS Use Only
Remarks
Returned
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
Date
Date
Date
Date
Date
Date
Date
USCIS
Form I-914
OMB No. 1615-0099
Expires 04/30/2021
Page 1
Form I-914, Supplement B 04/15/19
(USPS ZIP Code Lookup)