Form I-918 - Supplement B, U Nonimmigrant Status Certification Page 4
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5Part 5. Family Members Culpable In Criminal
Part 6. Certification
Activity
I am the head of the agency listed in Part 2. or I am the person
1.
Are any of the victim's family members culpable or
in the agency who was specifically designated by the head of
believed to be culpable in the criminal activity of which
the agency to issue a U Nonimmigrant Status Certification on
the petitioner is a victim?
behalf of the agency. Based upon investigation of the facts, I
Yes
No
certify, under penalty of perjury, that the individual identified in
If you answered "Yes," list the family members and their
Part 1. is or was a victim of one or more of the crimes listed in
criminal involvement. (If you need extra space to
Part 3. I certify that the above information is complete, true,
complete this section, use the space provided in Part 7.
and correct to the best of my knowledge, and that I have made
Additional Information.)
and will make no promises regarding the above victim's ability
to obtain a visa from U.S. Citizenship and Immigration Services
2.a. Family Name
(USCIS), based upon this certification. I further certify that if
(Last Name)
the victim unreasonably refuses to assist in the investigation or
2.b. Given Name
prosecution of the qualifying criminal activity of which he or
(First Name)
she is a victim, I will notify USCIS.
2.c. Middle Name
1.
Signature of Certifying Official (sign in ink)
2.d.
Relationship
2.
Date of Signature (mm/dd/yyyy)
2.e.
Involvement
3.
Daytime Telephone Number
3.a. Family Name
4.
Fax Number
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
3.d.
Relationship
3.e.
Involvement
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
4.d.
Relationship
4.e.
Involvement
Form I-918 Supplement B 02/07/17 N
Page 4 of 5
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