Form I-854b - Inter-Agency Alien Witness And Informant Record Page 2
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4Part 1. To be completed by Law Enforcement Agencies (continued)
D.
Other Information (continued)
Country of Issuance for Passport or Travel
Expiration Date for Passport or
Date of Last Entry into the U.S.
Travel Document (mm/dd/yyyy)
(mm/dd/yyyy)
Document
Place of Last Entry into the U.S. (City, State)
Class of Admission
Date of Birth (mm/dd/yyyy)
Current Immigration Status
Place of Birth
Country of Origin
Country of Citizenship or Nationality
Gender
Marital Status
Male
Female
Married
Never Married
Separated
Divorced
Widowed
Occupation
Select all documents
attached:
Form G-325
Form FD-258
Photos
Part 2. Certifications
Attach all relevant documentation establishing (1) the information certified below and (2) the recommendations and reasons for the
certified recommendations.
LEA Certification
I certify the above information is true and correct to the best of my knowledge; that no promises have been made regarding the above
alien's ability to adjust status or stay permanently in the United States other than those that comport with INA section 101(a)(15)(S);
that I have collected quarterly and annual reports detailing the above alien's whereabouts and activities and forwarded required
information to the Department of Justice, Criminal Division; and that the alien has fulfilled the terms of his or her admission and
classification. With this certification, I recommend the above mentioned person for adjustment of status under section 245(j) of the
INA.
Signature of Requesting Agent
Date (mm/dd/yyyy)
Title of Requesting Agent
Name of Requesting Agent
Signature of Headquarters (HQ) Chief of LEA
Date (mm/dd/yyyy)
Title of Certifier
Name of Headquarters (HQ) Chief of LEA
Form I-854B 07/13/17 N
Page 2 of 4
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