Form I-854 - Inter-Agency Alien Witness And Informant Record Page 3
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6Part B. Certifications
1. Alien Certification (S classification request)
I certify under penalty of perjury that I have reviewed with the LEA all the information in Part A, disclosed all information to the
best of my ability, and disclosed all reasons for which I may be removed from the United States; that I shall report at least every
three months my whereabouts and activities as the above LEA shall require; that I understand I am subject to removal for any
grounds of inadmissibility (conduct or condition) not disclosed at this time or for conduct committed after admission to the United
States; that I shall abide by all conditions, limitations and restrictions imposed upon my entry; that the classification I seek is
temporary and will terminate within three (3) years; that I am restricted by the terms of my admission to very specific means by
which I will be able to remain permanently in the United States; that I will pay Social Security and all applicable taxes on all
employment in the United States; and that I hereby waive my right to a removal hearing and to contest, other than on the basis of
an application for withholding of removal, any action for deportation instituted against me.
Certification: I certify that I have read and understand all the questions and statements on this form. If I do not understand
English, I further acknowledge that this has been read to me in a language I do understand. The answers I have furnished
are true and correct to the best of my knowledge and belief.
Date (mm/dd/yyyy)
Signature
Title
LEA Witness
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Translator
Language Used
2. LEA Certification
I certify the above information is true and correct to the best of my knowledge; that I may make, have made, and will make no
promises regarding the above alien's ability to adjust status or stay permanently in the United States other than those that comport
with section 101(a)(15)(S) of the Act; that I will collect quarterly reports detailing the above alien's whereabouts and activities and
forward required information to the Criminal Division; that I will immediately report to U.S. Immigration and Customs
Enforcement, DHS if this alien fails to report quarterly or fails to comply or to cooperate with the terms and conditions of
admission or if the alien commits any removable activity after the date of admission. I further certify that I assume complete law
enforcement responsibility for control and continued stay in lawful status of the alien, including necessary monitoring, travel
arrangements for arrival and departure, safety precautions and specified conditions of stay or departure; that I have provided a
sworn declaration as to the basis of this application and checked all available database information on the above alien, and that I
have carefully reviewed the above statements with the alien to ensure that all terms and conditions are understood.
Translation (This serves to verify the alien's certification of translation. See Page 2, Part B.1. of this form.)
Signature of HQ Chief of LEA
Title of Certifier
Date (mm/dd/yyyy)
Name of Agency Contact
Phone No. (Including Area Code)
Form I-854 (Rev. 05/13/10)Y Page 3
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