Form I-914 - Supplement B - Declaration Of Law Enforcement Officer For Victim Of Trafficking In Persons

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Supplement B, Delaration of Law Enforcement Officer for
Victim of Trafficking in Persons
USCIS
Form I-914
Department of Homeland Security
OMB No. 1615-0099
U.S. Citizenship and Immigration Services
Expires 01/31/2019
START HERE - Type or print in blank ink. This form should be completed by
For USCIS Use Only
Federal, State, or local law enforcement authorities for victims under the Victims of
Trafficking and Violence Protection Act, Public Law 106-386, as amended.
Returned
Receipt
Date
PART A. Victim Information
Family Name (Last Name)
Given Name (First Name)
Middle Name (if any)
Date
Resubmitted
Other Names Used (include maiden name/nickname)
Date
Date
Date of Birth (mm/dd/yyyy)
Gender
Reloc Sent
Male
Female
A # (if known)
Social Security # (if known)
Date
Date
Reloc Rec'd
Part B. Agency Information
Date
Name of Certifying Agency
Date
Name of Certifying Official
Title and Division/Office of Certifying Official
Remarks
Agency Address - Street Number and Name
Suite #
City
State/Province
Zip/Postal Code
Daytime Phone # (area code and/or extension)
Fax # (with area code)
Agency Type
Federal
State
Local
Case Status
On-going
Completed
Local
Certifying Agency Category
Judge
Law Enforcement
Prosecutor
Other
Case Number
FBI # or SID # (if applicable)
Part C. Statement of Claim
1. The applicant is or has been a victim of a severe form of trafficking in persons. Specifically, he or she is a victim of: (Check all
that apply. Base your analysis on the practices to which the victim was subjected rather than on the specific violations charged, the
counts on which convictions were obtained, or whether any prosecution resulted in convictions. Note that the definitions that
control this analysis are not the elements of criminal offenses, but are those set forth at 8 CFR 214.11(a).)
Sex trafficking in which a commercial sex act was induced by force, fraud, or coercion. Sex trafficking means the
recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act.
Sex trafficking and the victim is under the age of 18.
Form I-914, Supplement B 02/27/17 Y
Page 1

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