Form I-854 - Inter-Agency Alien Witness And Informant Record
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6OMB No. 1615-0046; Expires 05/31/2013
Form I-854, Inter-Agency Alien
Department of Homeland Security
Witness and Informant Record
U.S. Citizenship and Immigration Services
Part A. To be completed by Law Enforcement Agencies
(See instructions for specific information.)
Information must be Typed or Printed clearly.
1. Name of LEA/Requestor:
2. Requesting Agent:
Control Agent:
Address:
Phone No.(Including Area Code):
Fax No.(Including Area Code):
Check if applicable:
3.
U.S.
Alien will be placed in danger in
abroad
as a result of providing information, etc.
Alien poses no danger to people or property of the U.S.
If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish.
Investigation.
Prosecution.
United States Attorney involvement.
4. Type of Request(s). (Attach legal basis for request.)
S-5
S-6
Consular post at which visa will be sought:
Change of Status - If change of status is requested, current immigration status is
Adjustment of Status (Go to Part F after completing information in items 5, 6 and 7 below.)
Fees attached (when applicable)
Security concerns. State special instructions regarding security precautions.
NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of the
request and any bargain the requestor wishes to make or has made with the alien. Attach a complete criminal history, FBI
No. and U.S. Social Security Number.
5. Alien's Name (Last Name, First and Middle)
Other Names Used
Alien's Address (Street Number and Name)
A #
I-94 #
City
State or Province
Zip/Postal Code
Current Location of Alien
Marital Status
Date of Birth
Place of Birth (City or Country)
Citizenship/Nationality
Occupation
(mm/dd/yyyy)
Date of Last Entry into U.S.
Form G-325
Form FD-258
Photos
(mm/dd/yyyy):
attached
attached
attached
6. On a separate application, provide all information requested in item 5 above for each beneficary who seeks derivative status -
spouse, parents and all sons and daughters of the alien for whom an S classification is requested. (Attach additional sheets of
paper as necessary.)
Form I-854 (Rev. 05/13/10)Y
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