Form I-854 - Inter-Agency Alien Witness And Informant Record Page 2
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67a. The following information must be provided for each alien named in items 5 and 6 above.
Has the alien, while outside of the United States, ever committed, ordered, incited, assisted, or otherwise participated in
genocide, torture, or extrajudicial killing or participated in Nazi persecution?
Yes
No
If yes please write a detailed statement below and attach any relevant documents. (Attach additional
sheets of paper as needed.)
7b. For the above named alien, I request waiver(s) of the following grounds of inadmissibility. (Check all possible grounds and
attach all relevant documents establishing the ground(s) of inadmissibility and why you feel a waiver is appropriate for this
alien. This information must be provided for each alien named in items 5 and 6 above. Copy this check list of the grounds of
inadmissibility for each derivative.)
Communicable disease
Controlled substance trafficker
Prostitute and/or Procurer of Prostitution
Immigrant visa issued outside numerical limitation
Exercised diplomatic immunity to avoid prosecution
Crime involving moral turpitude
Unlawful activity related to National Security
International child abduction
Terrorist activities
Multiple criminal convictions
Communist Party member
Engaged in unlawful commercialized vice
Public charge
Entrance predudicial to public
Lacking labor certification
Involved in espionage, sabotage or laws relating to technology
Fraud/Misrepresentation
Coming to overthrow the U.S. Government
Immigrant without a visa
Foreign policy exclusion
Draft evader-was immigrant when left U.S.
Unqualified physician
Alien accompanying helpless inadmissible alien
Previously removed - aggravated felony
Violator of section 274C
Stowaway
Ordered, incited, assisted or otherwise participated in the
commission of the acts of torture or extra judicial killing.
Nonimmigrant without a valid passport or visa
Previously excluded and deported or removed
Engaged in conduct relating to severe violations of
religious freedoms
Alien smuggler
Weapons charges, domestic violence, and money
Physical/mental disorder (dangerous)
laundering
Drug abuser or addict
Other
Convicted of law pertaining to controlled substances
No waivers are requested/needed
Form I-854 (Rev. 05/13/10)Y Page 2
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