Fillable I-918supb Form I-918, Supplement B, U Nonimmigrant Status Certification

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I-918supb Form I-918, Supplement B, U Nonimmigrant Status Certification

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The I-918supb Form I-918, Supplement B, U Nonimmigrant Status Certification form is 5 pages long and contains:

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  • 58 check-boxes
  • 74 other fields

Country of origin: US
File type: PDF

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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-918 Supplement B 04/24/2019 Page 1 of 5
For
USCIS
Use
Only
Supplement B, U Nonimmigrant Status Certification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Page 1 of 5
START HERE - Type or print in black or blue ink.►
Part 1. Victim Information
Agency Address
Other Agency Information
Part 2. Agency Information
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Other Names Used (Include maiden names, nicknames, and
aliases, if applicable.)
4.
5. Gender Male
Female
1. Name of Certifying Agency
5.a.
5.c.
5.d.
5.g.
5.h.
5.i.
5.b.
Street Number
and Name
City or Town
State 5.f. ZIP Code
Ste. Flr.Apt.
Province
Postal Code
Country
7.
6.
9.
Case Status
Other
On-going Completed
StateFederal Local
Agency Type
8.
Remarks
Date of Birth (mm/dd/yyyy)
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
Middle Name
10.
Law Enforcement ProsecutorJudge
Other
Case Number
Certifying Agency Category
FBI Number or SID Number (if applicable)
Alien Registration Number (A-Number) (if any)1.
►
A-
If you need extra space to provide additional names, use the
space provided in Part 7. Additional Information.
USCIS
Form I-918
OMB No. 1615-0104
Expires 04/30/2021
3. Title and Division/Office of Certifying Official
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Name of Certifying Official
Name of Head of Certifying Agency
Form I-918 Supplement B 04/24/2019 Page 2 of 5
Did the criminal activity violate a Federal extraterritorial
jurisdiction statute?
1. The petitioner is a victim of criminal activity involving a
violation of one of the following Federal, state, or local
criminal offenses (or any similar activity). (Select all
applicable boxes)
False Imprisonment
Abduction
Abusive Sexual Contact
Blackmail
Domestic Violence
Extortion
Felonious Assault
Female Genital
Mutilation
Incest
Murder
Attempt to Commit
Any of the Named
Crimes
Sexual Assault
Obstruction of Justice
Peonage
Perjury
Prostitution
Rape
Sexual Exploitation
Torture
Trafficking
Unlawful Criminal
Restraint
Witness Tampering
Slave Trade
Stalking
Provide the dates on which the criminal activity occurred.
2.a.
Date (mm/dd/yyyy)
2.d.
Date (mm/dd/yyyy)
2.c.
Date (mm/dd/yyyy)
2.b.
Date (mm/dd/yyyy)
If you answered "Yes," provide the statutory citation
providing the authority for extraterritorial jurisdiction.
Briefly describe the criminal activity being investigated
and/or prosecuted and the involvement of the petitioner
named in Part 1. Attach copies of all relevant reports and
findings.
7. Provide a description of any known or documented injury
to the victim. Attach copies of all relevant reports and
findings.
6.
Yes No
5.b.
3.
List the statutory citations for the criminal activity being
investigated or prosecuted, or that was investigated or
prosecuted.
Part 3. Criminal Acts
5.a.
If you need extra space to complete this section, use the space
provided in Part 7. Additional Information.
If you answered "Yes," where did the criminal activity
occur?
4.b.
Kidnapping
Manslaughter
Fraud in Foreign Labor
Contracting
Conspiracy to Commit
Any of the Named
Crimes
Involuntary Servitude
Solicitation to
Commit Any of the
Named Crimes
4.a.
Yes No
Did the criminal activity occur in the United States
(including Indian country and military installations) or the
territories or possessions of the United States?
Being Held Hostage
Form I-918 Supplement B 04/24/2019 Page 3 of 5
Since the initiation of cooperation, has the victim refused
or failed to provide assistance reasonably requested in the
investigation or prosecution of the criminal activity
detailed above?
For the following questions, if the victim is under 16 years of
age, incompetent or incapacitated, then a parent, guardian, or
next friend may act on behalf of the victim.
1.
Yes No
3.
Yes No
Has the victim been helpful, is the victim being helpful, or
is the victim likely to be helpful in the investigation or
prosecution of the criminal activity detailed above?
2.
Does the victim possess information concerning the
criminal activity listed in Part 3.?
Yes No
Part 4. Helpfulness Of The Victim
If you answer "Yes" to Item Numbers 1. - 3., provide an
explanation in the space below. If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.
4. Other. Include any additional information you would like
to provide.
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.
Form I-918 Supplement B 04/24/2019 Page 5 of 5
Part 7. Additional Information
4.d.
If you need extra space to complete any item within this
supplement, use the space below or attach a separate sheet of
paper; type or print the agency's name, petitioner's name, and
the Alien Registration Number (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. If you need more space than what is provided, you
may also make copies of this page to complete and file with this
supplement.
Petitioner's Name
2.a.
Agency Name1.
Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
4.a. Page Number 4.b. Part Number 4.c. Item Number
5.d.
5.a.
Item Number6.c.Part Number6.b.Page Number6.a.
Page Number 5.b. Part Number 5.c. Item Number
6.d.
3. A-Number (if any)
►
A-
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I-918supb Form I-918, Supplement B, U Nonimmigrant Status Certification

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Completed 17 November 2019

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