Table of Changes Supp B Form

TABLE OF CHANGES – FORM

FORM I-914 SUPP B

12-10-2008

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1 – Instructions to Certifying Official	INSTRUCTIONS TO CERTIFYING OFFICER:  This applicant is applying for immigration benefits based upon a claim of having been a victim of a severe form of trafficking in persons.  Please complete the form below based upon your knowledge of the case, including evidence developed by other law enforcement officers investigating the case. In order to be granted immigration benefits, the applicant must demonstrate that he or she is present in the United States as a result of being a victim of a severe form of trafficking in persons. Unless the applicant is less than 18 years old, the applicant must also demonstrate that he or she is cooperating with law enforcement in the investigation and prosecution of the trafficking crime of which he or she was a victim. To be completed by Federal Law Enforcement Officers for victims under the Victims of Trafficking and Violence Protection Act, Public Law 106-386.	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.
New – Page 1		For USCIS Use Only Returned Receipt Date Date Resubmitted Date Date Reloc Sent Date Date Reloc Rec’d Date Date Remarks
Page 1 – Part A	General Information. Name of Government Agency: U.S. Citizenship and Immigration Services, DHS Civil Rights Division, DOJ U.S. Marshal’s Service, DOJ Federal Bureau of Investigation, DOJ Criminal Division, DOJ U.S. Attorney’s Office, DOJ Diplomatic Security, DOS Other Date (mm/dd/yyyy) Address of Agency/Official Name and Title of Certifying Officer or Official City State ZIP Code Phone No. Fax No. Victim’s Name Other Names Used Gender Male Female Date of Birth (mm/dd/yyyy) Date of Crime (mm/dd/yyyy) Charges Case No. Date Initiated (mm/dd/yyyy) Case Status On-going Completed N/A Date Completed (mm/dd/yyyy) FBI Identification No., if any	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)
Page 1	New Section	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 Case Number FBI # or SID # (if applicable)
Page 1 – Part B Add new questions	Part B. Statement of Claim.	Part C. Statement of Claim 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)
Page 2 – Part C	Part C. Cooperation of Victim. (Attach additional sheets, if necessary)	Part D. Cooperation of Victim (Attach additional sheets, if necessary)
Page 2 – Part D	Part D. Family Members. Are any of the applicant's relatives believed to have been involved in his or her trafficking to the United States? If Yes, list the relatives and describe that relative's involvement in the applicant's trafficking.	Part E. Family Members Implicated in Trafficking. 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
Page 2 – Part E	Part E. 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 the U.S. Citizenship and Immigration Services, based upon this certification. (Signature of Law Enforcement Officer identified in Box A above)	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 the 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)

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