Form I-854b - Inter-Agency Alien Witness And Informant Record

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Inter-Agency Alien Witness and
USCIS
Informant Adjustment of Status
Form I-854B
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.
In the space below, provide all the requested information for the alien for which adjustment of status
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
C.
Mailing Address
Street Number and Name
Apt.
Ste.
Flr.
Current Location of Alien (City, State)
City or Town
State
ZIP Code
D.
Other Information
Alien Registration Number
(A-Number) (if any)
S-Visa Number
Form I-94 Number
Passport Number
Travel Document Number
Form I-854B 07/13/17 N
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