Form I-854b - Inter-Agency Alien Witness And Informant Record Page 3
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4Part 2. Certifications (continued)
Office Name and Mailing Address
Office Name
Street Number and Name
Apt.
Ste.
Flr.
City or Town
State
ZIP Code
Office Contact Information
Daytime Telephone Number
Fax Number
E-mail Address
The Department of Justice, Criminal Division (Assistant Attorney General) Certifications
I certify that the alien,
, has -
If S-5, S-6, or S-7:
Abided by all terms and conditions of the S classification.
If S-5:
Substantially contributed information to the success of an authorized criminal investigation or the prosecution of
an individual as per terms of entry.
Supplied the information that formed the basis of entry.
If S-6:
Substantially contributed information to the prevention or frustration of an act of terrorism against a U.S. person or
property or the success of an authorized criminal investigation of, or the prosecution of, an individual involved in
such an act of terrorism.
Supplied the information that formed the basis of entry.
Received a reward under section 36(a) of the State Department Basic Authorities Act of 1956.
Abided by all specific 22 U.S.C. 2708(a) limitations of the S classification.
If S-7:
The S-5 or S-6 alien through which this alien obtained S classification through has abided by all terms, conditions
of the S classification, and is recommended for adjustment.
Other Comments:
Title
Signature
Date (mm/dd/yyyy)
Name
Form I-854B 07/13/17 N
Page 3 of 4
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