Fillable I-914-Supplement-B-min Form I-914

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I-914-Supplement-B-min Form I-914

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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 #
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 # (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 01/31/2019
Page 1
Form I-914, Supplement B 02/27/17 Y
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.
Not applicable.
Other, specify on attached additional sheets.
2. Please describe the victimization upon which the applicant's claim is based and identify the relationship between that victimization
and the crime under investigation/prosecution. 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.
Date (mm/dd/yyyy)
4. Provide the date(s) on which the acts of trafficking occurred.
Date (mm/dd/yyyy) Date (mm/dd/yyyy)Date (mm/dd/yyyy)
5. List the statutory citation(s) for the acts of trafficking being investigated or prosecuted, or that were investigated or prosecuted.
6. Provide the date on which the investigation or prosecution was initiated.
Date (mm/dd/yyyy)
7. Provide the date on which the investigation or prosecution was completed (if any).
Date (mm/dd/yyyy)
Part C. Statement of Claim (Continued)
Page 2
Form I-914, Supplement B 02/27/17 Y
Part E. Family Members Implicated In Trafficking
Part F. Attestation
NoYes
Are any of the applicant's family members believed to have been involved in his or her trafficking to the United
States? If "Yes," list the relative(s) and describe the involvement. Attach additional sheets if necessary.
Full Name Relationship
Involvement
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, based upon this certification. I further certify that if the victim unreasonably refuses to assist in
the investigation or prosecution of the acts of trafficking of which he/she is a victim, I will notify USCIS.
Date (mm/dd/yyyy)
Signature of Law Enforcement Officer (identified in Part B) (sign in ink)
Date (mm/dd/yyyy)
Signature of Supervisor of Certifying Officer (sign in ink)
Printed Name of Supervisor
Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has not been requested to assist in the investigation/prosecution of any crime of trafficking.
Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (Explain below.)
Other, specify on attached additional sheets.
Has not yet attained the age of 18.
The applicant:
Part D. Cooperation of Victim (Attach additional sheets, if necessary)
Page 3
Form I-914, Supplement B 02/27/17 Y
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I-914-Supplement-B-min Form I-914

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Completed 12 July 2020

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