Form I-854B 07/13/17 N Page 2 of 4
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
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)
Part 2. Certifications
Attach all relevant documentation establishing (1) the information certified below and (2) the recommendations and reasons for the
certified recommendations.
LEA Certification
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
I certify the above information is true and correct to the best of my knowledge; that no promises have been made regarding the above
alien's ability to adjust status or stay permanently in the United States other than those that comport with INA section 101(a)(15)(S);
that I have collected quarterly and annual reports detailing the above alien's whereabouts and activities and forwarded required
information to the Department of Justice, Criminal Division; and that the alien has fulfilled the terms of his or her admission and
classification. With this certification, I recommend the above mentioned person for adjustment of status under section 245(j) of the
INA.
Other Information (continued)D.
Place of Last Entry into the U.S. (City, State)
Country of Issuance for Passport or Travel
Document
Date of Last Entry into the U.S.
(mm/dd/yyyy)
Expiration Date for Passport or
Travel Document (mm/dd/yyyy)