Form I-854a - Inter-Agency Alien Witness And Informant Record
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8Inter-Agency Alien Witness
USCIS
and Informant Record
Form I-854A
Department of Homeland Security
OMB No. 1615-0046
U.S. Citizenship and Immigration Services
Expires 07/31/2019
START HERE - Type or print in black ink.
Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.)
1.
Name of Law Enforcement Agency (LEA)/Requestor
2.
Requesting Agent (Special Agent in Charge, Chief of Police, etc.)
Control Agent
3. Mailing Address
Street Number and Name
Apt.
Ste.
Flr.
City or Town
State
ZIP Code
4. Contact Information
Daytime Telephone Number
Fax Number
E-mail Address
5. Select all applicable boxes.
As a result of providing information, the alien will be placed in danger:
in the United States or
abroad.
The alien poses no danger to people or property of the United States.
If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish.
Investigation.
Prosecution.
United States Attorney involvement.
6. Type of Requests. (Attach legal basis for request.)
S-5
S-6
S-7
Consular post at which visa will be sought:
NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of
the request, and any bargain the LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI
Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding
security precautions.
7.
In the space below, provide all the requested information for the alien for whom an S classification is requested.
A. Alien's Current Legal Name (do not provide a nickname)
Family Name (Last Name)
Given Name (First Name)
Middle Name
B.
Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Form I-854A 07/13/17 N
Page 1 of 8
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