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Supplement B Declaration Of Law Enforcement Officer For Victim Of Trafficking In Persons I-914 - Official Federal Forms
| Supplement B Declaration Of Law Enforcement Officer For Victim Of Trafficking In Persons Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0099; Expires 05/31/2014 Department of Homeland Security U.S. Citizenship and Immigration Services Form I-914, Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons For USCIS Use Only Returned Date Middle Name (if any) Date Resubmitted Date Receipt 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. PART A. Victim Information Family Name (Last Name) Given Name (First Name) Other Names Used (include maiden name/nickname) Date of Birth (mm/dd/yyyy) A # (if known) Gender Male Social Security # (if known) Female Date Reloc Sent Date Date Reloc Rec'd Date Title and Division/Office of Certifying Official Date Remarks Agency Address - Street Number and Name City State/Province Suite # Zip/Postal Code Fax # (with area code) Part B. Agency Information Name of Certifying Agency Name of Certifying Official Daytime Phone # (area code and/or extension) Agency Type Federal Case Status On-going State Local Completed Local Prosecutor Other Certifying Agency Category Judge Law Enforcement Case Number FBI # or SID # (if applicable) Part C. Statement of Claim 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).) 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. Sex trafficking and the victim is under the age of 18. Form I-914, Supplement B (Rev. 05/04/12) Y American LegalNet, Inc. www.FormsWorkFlow.com Part C. Statement of Claim (Continued) 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. 4. Provide the date(s) on which the acts of trafficking occurred. Date (mm/dd/yyyy) 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) Form I-914, Supplement B (Rev. 05/04/12) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part D. Cooperation of Victim (Attach additional sheets, if necessary) The applicant: Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.) Has failed to comply with requests to assist 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 not yet attained the age of 18. Other, specify on attached additional sheets. Part E. Family Members Implicated In Trafficking Yes No 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 Part F. Attestation 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. Signature of Law Enforcement Officer (identified in Part B) Date (mm/dd/yyyy) Signature of Supervisor of Certifying Officer Date (mm/dd/yyyy) Printed Name of Supervisor Form I-914, Supplement B (Rev. 05/04/12) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com
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