Form I 914 Supplement B PDF Details

Form I-914 Supplement B is used to request a waiver of the foreign national’s inadmissibility. This form should be completed and submitted together with Form I-914, Application for T Nonimmigrant Status, when applying for TN visa status. There are several grounds of inadmissibility that may be waived using Supplement B, including unlawful presence in the United States and unlawful entry. The most common reason for requesting a waiver using Supplement B is because the foreign national has been refused admission or removed from the United States. For more information on how to complete and submit Supplement B, please consult the instructions provided by USCIS.

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Form NameForm I 914 Supplement B
Form Length3 pages
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OMB No. 1615-0099; Expires 05/31/2014

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-914, Supplement B, Declaration of Law Enforcement Officer for Victim of Trafficking in Persons

START HERE - Type or print in blank ink. This form should be completed by Federal, State, or local law enforcement authorities for victims under the Victims of Trafficking and Violence Protection Act, Public Law 106-386, as amended.

PART A. Victim Information

Family Name (Last Name)

Given Name (First Name) Middle Name (if any)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Names Used (include maiden name/nickname)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

Gender

 

 

 

 

 

 

 

 

Male

Female

A # (if known)

 

 

Social Security # (if known)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part B. Agency Information

Name of Certifying Agency

Name of Certifying Official

 

Title and Division/Office of Certifying Official

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Address - Street Number and Name

 

 

 

 

 

 

 

Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State/Province

 

 

 

 

Zip/Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone # (area code and/or extension)

 

Fax # (with area code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agency Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal

State

 

Local

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On-going

Completed

 

Local

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certifying Agency Category

 

 

 

 

 

 

 

 

 

 

 

 

Judge

Law Enforcement

 

Prosecutor

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For USCIS Use Only

 

 

Returned

Receipt

 

 

Date

 

 

 

Date

 

Resubmitted

 

 

 

Date

 

 

 

Date

 

Reloc Sent

 

 

 

Date

 

 

 

Date

 

Reloc Rec'd

 

 

 

Date

 

 

 

Date

 

 

 

Remarks

 

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

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.

Full Name

Relationship

Involvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

Signature of Supervisor of Certifying Officer

Date (mm/dd/yyyy)

Printed Name of Supervisor

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