Form I-918 Supplement B 04/24/2019 Page 4 of 5
Are any of the victim's family members culpable or
believed to be culpable in the criminal activity of which
the petitioner is a victim?
Part 5. Family Members Culpable In Criminal
Activity
Yes No
If you answered "Yes," list the family members and their
criminal involvement. (If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.)
1.
2.a. Family Name
(Last Name)
2.b.
Given Name
(First Name)
2.c. Middle Name
Relationship2.d.
Involvement
2.e.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
Relationship
3.d.
Involvement3.e.
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Relationship4.d.
Involvement4.e.
Part 6. Certification
I am the head of the agency listed in Part 2. or I am the person
in the agency who was specifically designated by the head of
the agency to issue a U Nonimmigrant Status Certification on
behalf of the agency. Based upon investigation of the facts, I
certify, under penalty of perjury, that the individual identified in
Part 1. is or was a victim of one or more of the crimes listed in
Part 3. I certify that the above information is complete, 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 unreasonably refuses to assist in the investigation or
prosecution of the qualifying criminal activity of which he or
she is a victim, I will notify USCIS.
Signature of Certifying Official (sign in ink)
2.
1.
Date of Signature (mm/dd/yyyy)
Fax Number4.
Daytime Telephone Number3.