Form I 914 Supplement B – Fill Out and Use This PDF

OMB No. 1615-0099; Expires 05/31/2014

Case Number		FBI # or SID # (if applicable)

Part C. Statement of Claim

1.The applicant is or has been a victim of a severe form of trafficking in persons. Specifically, he or she is a victim of: (Check all that apply. Base your analysis on the practices to which the victim was subjected rather than on the specific violations charged, the counts on which convictions were obtained, or whether any prosecution resulted in convictions. Note that the definitions that control this analysis are not the elements of criminal offenses, but are those set forth at 8 CFR 214.11(a).)

Sex trafficking in which a commercial sex act was induced by force, fraud, or coercion. Sex trafficking means the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act.

Sex trafficking and the victim is under the age of 18.

Form I-914, Supplement B (Rev. 05/04/12) Y

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 (Rev. 05/04/12) Y Page 2

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

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)		Date (mm/dd/yyyy)

Printed Name of Supervisor

Form I-914, Supplement B (Rev. 05/04/12) Y Page 3