Current Page Number and
Section
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Current Text
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Proposed
Text
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Page 1
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[Page 1]
For USCIS Use Only
Remarks
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[Page 1]
For
Certifying Agency Use Only (Certification Tracking Information)
[fillable field]
For USCIS
Use Only
Remarks
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Page 1, Start Here
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[Page 1]
START HERE - Type or print in
black or blue ink.
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[Page 1]
START HERE - Type or print in
black ink.
Answer all
questions fully and accurately.
If you need extra space to provide additional information for any
question, use the space provided in Part
10. Additional Information.
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Page 1,
Part 1. Victim
Information
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[Page 1]
Part 1. Victim Information
1. Alien Registration Number
(A-Number) (if any)
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
Other Names Used (Include
maiden names, nicknames, and aliases, if applicable.)
If you need extra space to provide
additional names, use the space provided in Part 7. Additional
Information.
3.a. Family Name (Last Name)
3.b. Given Name (First Name)
3.c. Middle Name
4. Date of Birth
(mm/dd/yyyy)
[moved down from above]
5. Gender
Male
Female
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[Page 1]
Part 1. General
Information About The Victim
[moved down to
Item Number 4.]
1. Victim’s
Full Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name (if
applicable)
2. Other
Names Used
Family
Name (Last Name) [x2]
Given Name (First Name) [x2]
Middle Name (if
applicable) [x2]
3.
Date of Birth (mm/dd/yyyy)
4.
Alien Registration Number (A-Number) (if any)
5. Gender
Male
Female
Another Gender
Identity
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Page 1,
Part 2. Agency
Information
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[Page 1]
Part 2. Agency Information
[new]
1. Name of Certifying Agency
Name of Certifying Official
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
[moved down from above]
3. Title and Division/Office
of Certifying Official
[new]
Name of Head of Certifying Agency
4.a. Family Name (Last Name)
4.b. Given Name (First Name)
4.c. Middle Name
[new]
Agency Address
5.a. Street Number and Name
5.b. Apt./Ste./Flr.
5.c. City or Town
5.d. State
5.f. ZIP Code
5.g. Province
5.h. Postal Code
5.i. Country
Other Agency Information
6. Agency Type
Federal
State
Local
7. Case Status
On-going
Completed
Other
8. Certifying Agency
Category
Judge
Law Enforcement
Prosecutor
Other
9. Case Number
10. FBI Number or SID Number
(if applicable)
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[Page 1]
Part 2. Information About
You (Certifying Official)
[] I am the
head of the certifying agency
[] I have been
designated as the certifying official by the head of my agency
[] I am a
judge.
[moved down]
1. Your
Name (Certifying Official)
Family Name (Last Name)
Given Name (First Name)
Middle
Name (if applicable)
2. Name
of Your Certifying Agency
3. Your
Position Title and Division or Office
[Page 2]
If you are not
the head of your agency, answer Item
Numbers 4. - 5.
NOTE:
Judges do not need to fill out Item
Numbers 4. - 5.
4. Name
of the Head of Your
Certifying Agency
Family Name (Last Name)
Given Name (First Name)
Middle Name (if
applicable)
5. Position
Title of the Head of Your Certifying
Agency
6. Physical
Address of Your Agency
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Other
Agency Information
7.
Agency Type (select
one): Federal /
State /
Local /
Tribal
/ Territorial
[deleted]
8.
Certifying Agency Category
(select one): Judge
/ Law Enforcement /
Prosecutor / Other
[fillable
field]
[deleted]
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[new]
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[Page 2]
Part 3.
Case Information
1.
Case Status
(select one):
Active/Ongoing Investigation;
Closed Investigation
2.
Case Number (if any)
3.
FBI Universal Control Number
(UCN) (if applicable)
4. State
Identification (SID) Number
(if applicable)
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Page 2, Part 3.
Criminal Acts
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[Page 2]
Part 3. Criminal Acts
If you need extra space to complete
this section, use the space provided in Part 7. Additional
Information.
[new]
1. The petitioner is a
victim of criminal activity involving a violation of one of the
following Federal, state, or local criminal offenses (or any
similar activity). (Select all applicable boxes)
Abduction
Abusive Sexual Contact
Attempt to Commit Any of the Named
Crimes
Being Held Hostage
Blackmail
Conspiracy to Commit Any of the
Named Crimes
Domestic Violence
Extortion
False Imprisonment
Felonious Assault
Female Genital Mutilation
Fraud in Foreign Labor Contracting
Incest
Involuntary Servitude
Kidnapping
Manslaughter
Murder
Obstruction of Justice
Peonage
Perjury
Prostitution
Rape
Sexual Assault
Sexual Exploitation
Slave Trade
Solicitation to Commit Any of the
Named Crimes
Stalking
Torture
Trafficking
Unlawful Criminal Restraint
Witness Tampering
Provide the dates on which the
criminal activity occurred.
2.a. Date (mm/dd/yyyy)
2.b. Date (mm/dd/yyyy)
2.c. Date (mm/dd/yyyy)
2.d. Date (mm/dd/yyyy)
3. List the statutory
citations for the criminal activity being investigated or
prosecuted, or that was investigated or prosecuted.
[new]
4.a. Did the criminal
activity occur in the United States (including Indian country and
military installations) or the territories or possessions of the
United States?
Yes
No
4.b. If you answered "Yes,"
where did the criminal activity occur?
5.a. Did the criminal
activity violate a Federal extraterritorial jurisdiction statute?
Yes
No
5.b. If you answered "Yes,"
provide the statutory citation providing the authority for
extraterritorial jurisdiction.
6. Briefly describe the
criminal activity being investigated and/or prosecuted and the
involvement of the petitioner named in Part 1. Attach
copies of all relevant reports and findings.
7. Provide a description of
any known or documented injury to the victim. Attach copies of
all relevant reports and findings.
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[Page 2]
Part 4.
Qualifying Criminal Activity
Perpetrated Against The Victim
If you need extra space to complete
this section, use the space provided in Part 10.
Additional Information.
Qualifying
Criminal Activity Category
NOTE:
USCIS is solely responsible for
determining whether the crime(s) listed below is a “qualifying
criminal activity” for purposes of eligibility for U
nonimmigrant status.
[Page 3]
1. The
person listed in Part
1. is a victim of the following
crimes (list the statutory citations for the qualifying criminal
activity detected, investigated, or prosecuted) and provide the
dates on which the qualifying criminal activity occurred:
[Table 2
columns with 4 rows]
Statutory
Citations for Qualifying
Criminal Activity
Dates of
Qualifying Criminal
Activity
2. Describe
the qualifying criminal activity being detected, investigated,
and/or prosecuted.
Attach copies of all relevant reports and outcomes.
3.
The qualifying criminal activity in Part
4.,
Item Number 1.
appears to fall under one or more of the following categories.
(Select all
applicable boxes.)
Abduction
Abusive Sexual
Contact
Attempt to
Commit Any of the Named Crimes
Being Held
Hostage
Blackmail
Conspiracy to
Commit Any of the Named Crimes
Domestic
Violence
Extortion
False
Imprisonment
Felonious
Assault
Female Genital
Mutilation
Fraud in
Foreign Labor Contracting
Incest
Involuntary
Servitude
Kidnapping
Manslaughter
Murder
Obstruction of
Justice
Peonage
Perjury
Prostitution
Rape
Sexual Assault
Sexual
Exploitation
Slave Trade
Solicitation
to Commit Any of the Named Crimes
Stalking
Torture
Trafficking
Unlawful
Criminal Restraint
Witness
Tampering
[deleted]
[Page 4]
4.
If the qualifying criminal activity
listed at Part 4.,
Item Number 1. is similar to one or more of the above selected
categories listed in Part
4., Item
Number 3. (for example, felonious
assault), please list and provide a detailed description of the
criminal activities you detected, investigated, or prosecuted.
Culpability
in Qualifying Criminal Activity
5.
The
victim was culpable in the qualifying criminal activity detected,
investigated, or prosecuted. If you answered “Yes,”
provide an explanation in Part
10. Additional Information.
Attach copies of all relevant reports and findings.
Yes
/ No
Jurisdiction
6.
Did the qualifying criminal activity
occur in the United States (including Indian country and military
installations) or the territories or possessions of the United
States? If
you answered “Yes,” please indicate where the
qualifying criminal activity occurred.
Yes/No
[fillable
field]
7.
Did the qualifying criminal activity
violate a Federal extraterritorial jurisdiction statute? If
you answered “Yes,” provide the statutory citation
providing the authority for extraterritorial jurisdiction.
Yes
No
[fillable
field]
[Renumbered to
Item Number 2.
in Qualifying Criminal Activity
Category]
[Reorganized
into Part
5. Known Or Documented Injury To The Victim]
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|
[new]
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[Page 5]
Part
5. Known Or Documented Injury To The Victim
1.
Provide a description of any known or documented injury to the
victim. Attach copies of all relevant reports and findings.
[fillable field]
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Page 3,
Part 4. Helpfulness
Of The Victim
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[Page 3]
Part 4. Helpfulness Of The
Victim
For the following questions, if the
victim is under 16 years of age, incompetent or incapacitated,
then a parent, guardian, or next friend may act on behalf of the
victim.
1. Does the victim possess
information concerning the criminal activity listed in Part 3.?
Yes
No
2. Has the victim been
helpful, is the victim being helpful, or is the victim likely to
be helpful in the investigation or prosecution of the criminal
activity detailed above?
Yes
No
3. Since the initiation of
cooperation, has the victim refused or failed to provide
assistance reasonably requested in the investigation or
prosecution of the criminal activity detailed above?
Yes
No
If you answer "Yes" to
Item Numbers 1. - 3., provide an explanation in the space
below. If you need extra space to complete this section, use the
space provided in Part 7. Additional Information.
4. Other. Include any
additional information you would like to provide.
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[Page 5]
Part 6.
Helpfulness Of The Victim
For the following questions, if the
victim is under 16 years of age, or is
incompetent or incapacitated, then a parent, guardian, or
next friend may act on behalf of the victim.
1. Does the victim possess
information concerning the qualifying
criminal activity listed in Part 4.?
Yes / No
2. The
victim has been, is being, or is likely to be helpful in the
detection, investigation, or prosecution of the qualifying
criminal activity detailed above.
Yes/No
3.
Since
the initiation of cooperation, has the victim refused or failed to
provide assistance reasonably requested in the investigation or
prosecution of the
qualifying criminal activity
detailed above?
Yes/No
If
you answer “Yes” to Item
Numbers 1. - 3.,
provide an explanation in the space below. If you need extra
space to complete this section, use the space provided in Part
10. Additional Information.
[fillable
field for a narrative explanation]
[deleted]
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Page 4,
Part 5. Family
Members Culpable In Criminal Activity
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[Page 4]
Part 5. Family Members Culpable
In Criminal Activity
1. Are any of the victim's
family members culpable or believed to be culpable in the criminal
activity of which the petitioner is a victim?
Yes
No
If you answered "Yes,"
list the family members and their criminal involvement. (If you
need extra space to complete this section, use the space provided
in Part 7. Additional Information.)
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
2.d. Relationship
2.e. Involvement
3.a. Family Name (Last Name)
3.b. Given Name (First Name)
3.c. Middle Name
3.d. Relationship
3.e. Involvement
4.a. Family Name (Last Name)
4.b. Given Name (First Name)
4.c. Middle Name
4.d. Relationship
4.e. Involvement
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[Page 6]
Part 7.
Victim’s Family Members Culpable In
The Qualifying Criminal
Activity
[deleted]
If any
of the victim's family members are culpable
or believed to be culpable in the qualifying
criminal activity perpetrated against
the victim, list the family members and their
criminal involvement.
1. Family
Member 1
Family Name (Last Name)
Given Name (First Name)
Middle Name
(if known)
2. Relationship
to victim
3.
Involvement
4. Family
Member 2
Family Name (Last Name)
Given Name (First Name)
Middle Name (if
known)
5.
Relationship to victim
6.
Involvement
[deleted]
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[new]
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[Page 6]
Part
8. Supplemental Information
1.
If you would like to share any additional information you think is
relevant to this certification, provide specific details.
Attach all relevant documentation and records.
[Text
field - leave 3 lines.]
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Page 4,
Part 6.
Certification
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[Page 4]
Part 6. Certification
I am the head of the agency listed
in Part 2. or I am the person in the agency who was
specifically designated by the head of the agency to issue a U
Nonimmigrant Status Certification on behalf of the agency. Based
upon investigation of the facts, I certify, under penalty of
perjury, that the individual identified in Part 1. is or
was a victim of one or more of the crimes listed in Part 3.
I certify that the above information is complete, 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 (USCIS), based
upon this certification. I further certify that if the victim
unreasonably refuses to assist in the investigation or prosecution
of the qualifying criminal activity of which he or she is a
victim, I will notify USCIS.
1. Signature of Certifying
Official (sign in ink)
2. Date of Signature
(mm/dd/yyyy)
3. Daytime Telephone Number
[new]
4. Fax Number
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[Page 6]
Part 9.
Certification
As the head of
the agency or the person designated by the head of the agency, or
a person otherwise authorized by INA Section 214(p)(1) to sign
certifications, I certify, under penalty of perjury,
that the foregoing is true and correct.
The
individual identified in Part 1. is or was a victim of one
or more of the qualifying criminal
activities listed in Part 4.
My agency has
been or is involved in the detection, investigation, prosecution,
conviction, sentencing of one or more of the qualifying criminal
activities listed in Part 4.
The individual
has been, is being, or is likely to be helpful in the detection,
investigation, prosecution, conviction, sentencing of the
qualifying criminal activity.
NOTE: If
you are a designated certifying official and your name and
signature has not been provided to USCIS, or if your agency needs
to otherwise update its list certifying official(s), see page 2 of
the Form I-918, Supplement B, “Instructions for Certifying
Officials” for further guidance.
1. Signature of Certifying
Official
2. Date of Signature
(mm/dd/yyyy)
3. Daytime Telephone Number
4. Email
Address
5.
Fax Number
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Page 5,
Part 7. Additional
Information
|
[Page 5]
Part 7. Additional Information
If you need extra space to complete
any item within this supplement, use the space below or attach a
separate sheet of paper; type or print the agency's name,
petitioner's name, and the Alien Registration Number (A-Number)
(if any) at the top of each sheet; indicate the Page Number,
Part Number, and Item Number to which your answer
refers; and sign and date each sheet. If you need more space than
what is provided, you may also make copies of this page to
complete and file with this supplement.
1. Agency Name
Petitioner's Name
2.a. Family Name (Last Name)
2.b. Given Name (First Name)
2.c. Middle Name
3. A-Number (if any)
4.a. Page Number
4.b. Part Number
4.c. Item Number
4.d.
5.a. Page Number
5.b. Part Number
5.c. Item Number
5.d.
6.a. Page Number
6.b. Part Number
6.c. Item Number
6.d.
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[Page 7]
Part 10. Additional
Information
If you need extra space to provide
additional information within this supplement, use the
space below. If you need more space than
what is provided, you may make copies of this page and file with
this supplement or attach a separate sheet of paper. Type
or print the agency's name, victim’s
name, and the A-Number at the
top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers;
and sign and date each sheet.
[delete]
1. Page
Number
Part Number
Item Number
[fillable field]
2. Page
Number
Part Number
Item Number
[fillable field]
3. Page
Number
Part Number
Item Number
[fillable field]
4. Page
Number
Part Number
Item Number
[fillable
field]
5. Page
Number
Part Number
Item Number
[fillable
field]
6. Page
Number
Part Number
Item Number
[fillable
field]
7. Page
Number
Part Number
Item Number
[fillable
field]
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