Form I-914 - Supplement B - Declaration Of Law Enforcement Officer For Victim Of Trafficking In Persons Page 2

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Part C. Statement of Claim
(Continued)
The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force,
fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery.
Not applicable.
Other, specify on attached additional sheets.
2. Please describe the victimization upon which the applicant's claim is based and identify the relationship between that victimization
and the crime under investigation/prosecution. Attach the results of any name or database inquiry performed in the investigation of
the case, as well as any relevant reports and findings. Include relevant dates, etc. Attach additional sheets, if necessary.
3. Has the applicant expressed any fear of retaliation or revenge if removed from the United States? If yes, explain. Attach additional
sheets, if necessary.
4. Provide the date(s) on which the acts of trafficking occurred.
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
5. List the statutory citation(s) for the acts of trafficking being investigated or prosecuted, or that were investigated or prosecuted.
6. Provide the date on which the investigation or prosecution was initiated.
Date (mm/dd/yyyy)
7. Provide the date on which the investigation or prosecution was completed (if any).
Date (mm/dd/yyyy)
Form I-914, Supplement B 02/27/17 Y
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