Form I-918 Supplement B, U Nonimmigrant Status Certification Page 3
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3Part 4. Helpfulness of the Victim (continued)
5. Other, please specify.
Part 5. Family Members Implicated in Criminal Activity
1. Are any of the victim's family members believed to have been involved in the criminal activity of
Yes
No
which he or she is a victim?
2. If "Yes," list relative(s) and criminal involvement. (Attach extra reports or extra sheet(s) of paper if necessary.)
Full Name
Relationship
Involvement
art 6. Certification
P
I am the head of the agency listed in Part 2 or I am the person in the agency who has been specifically designated by the head of the
agency to issue U nonimmigrant status certification on behalf of the agency. Based upon investigation of the facts, I certify, under
penalty of perjury, that the individual noted in Part 1 is or has been a victim of one or more of the crimes listed in Part 3. 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 the 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 qualifying criminal activity of which
he/she is a victim, I will notify USCIS.
Signature of Certifying Official Identified in Part 2.
Date (mm/dd/yyyy)
Form I-918 Supplement B (01/15/13) Y Page 3
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