Form I-914 - Supplement B - Declaration Of Law Enforcement Officer For Victim Of Trafficking In Persons Page 3

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Part D. Cooperation of Victim (Attach additional sheets, if necessary)
The applicant:
Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (Explain below.)
Has not been requested to assist in the investigation/prosecution of any crime of trafficking.
Has not yet attained the age of 18.
Other, specify on attached additional sheets.
Part E. Family Members Implicated In Trafficking
Yes
No
Are any of the applicant's family members believed to have been involved in his or her trafficking to the United
States? If "Yes," list the relative(s) and describe the involvement. Attach additional sheets if necessary.
Involvement
Full Name
Relationship
Part F. Attestation
Based upon investigation of the facts, I certify, under penalty of perjury, that the above noted individual is or has been a victim of a
severe form of trafficking in persons as defined by the VTVPA. I certify that the above information is true and correct to the best of
my knowledge, and that I have made, and will make, no promises regarding the above victim's ability to obtain a visa from U.S.
Citizenship and Immigration Services, based upon this certification. I further certify that if the victim unreasonably refuses to assist in
the investigation or prosecution of the acts of trafficking of which he/she is a victim, I will notify USCIS.
Signature of Law Enforcement Officer (identified in Part B) (sign in ink)
Date (mm/dd/yyyy)
Signature of Supervisor of Certifying Officer (sign in ink)
Date (mm/dd/yyyy)
Printed Name of Supervisor
Form I-914, Supplement B 02/27/17 Y
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