Inter-Agency Alien Witness and Informant Adjustment of Status Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in black ink. OMB No. 1615-0046 Expires 03/31/2017 USCIS Form I-854B Part 1. To Be Completed By Law Enforcement Agencies (See instructions for specific information.) 1. 2. 3. Name of Law Enforcement Agency (LEA)/Requestor Requesting Agent (Special Agent in Charge, Chief of Police, etc.) Mailing Address Street Number and Name City or Town 4. Contact Information Daytime Telephone Number 5. Fax Number E-mail Address Apt. Ste. Flr. State ZIP Code Control Agent In the space below, provide all the requested information for the alien for which adjustment of status is requested. A. Alien's Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name B. Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable) Family Name (Last Name) Given Name (First Name) Middle Name C. Mailing Address Street Number and Name City or Town D. Other Information S-Visa Number Alien Registration Number (A-Number) (if any) Form I-94 Number State ZIP Code Apt. Ste. Flr. Current Location of Alien (City, State) Passport Number Travel Document Number Form I-854B 03/13/15 N Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 1. To be completed by Law Enforcement Agencies (continued) D. Other Information (continued) Country of Issuance for Passport or Travel Document Place of Last Entry into the U.S. (City, State) Current Immigration Status Place of Birth Country of Origin Gender Male Occupation Marital Status Married Country of Citizenship or Nationality Expiration Date for Passport or Travel Document (mm/dd/yyyy) Date of Last Entry into the U.S. (mm/dd/yyyy) Class of Admission Date of Birth (mm/dd/yyyy) Female Never Married Separated Form G-325 Divorced Widowed Photos Select all documents attached: Form FD-258 Part 2. Certifications Attach all relevant documentation establishing (1) the information certified below and (2) the recommendations and reasons for the certified recommendations. LEA Certification I certify the above information is true and correct to the best of my knowledge; that no promises have been made regarding the above alien's ability to adjust status or stay permanently in the United States other than those that comport with INA section 101(a)(15)(S); that I have collected quarterly and annual reports detailing the above alien's whereabouts and activities and forwarded required information to the Department of Justice, Criminal Division; and that the alien has fulfilled the terms of his or her admission and classification. With this certification, I recommend the above mentioned person for adjustment of status under section 245(j) of the INA. Signature of Requesting Agent Name of Requesting Agent Date (mm/dd/yyyy) Title of Requesting Agent Signature of Headquarters (HQ) Chief of LEA Name of Headquarters (HQ) Chief of LEA Date (mm/dd/yyyy) Title of Certifier Form I-854B 03/13/15 N Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Certifications (continued) Office Name and Mailing Address Office Name Street Number and Name City or Town Office Contact Information Daytime Telephone Number Fax Number E-mail Address Apt. Ste. Flr. State ZIP Code The Department of Justice, Criminal Division (Assistant Attorney General) Certifications I certify that the alien, If S-5, S-6, or S-7: If S-5: Abided by all terms and conditions of the S classification. , has - Substantially contributed information to the success of an authorized criminal investigation or the prosecution of an individual as per terms of entry. Supplied the information that formed the basis of entry. If S-6: Substantially contributed information to the prevention or frustration of an act of terrorism against a U.S. person or property or the success of an authorized criminal investigation of, or the prosecution of, an individual involved in such an act of terrorism. Supplied the information that formed the basis of entry. Received a reward under section 36(a) of the State Department Basic Authorities Act of 1956. Abided by all specific 22 U.S.C. 2708(a) limitations of the S classification. If S-7: The S-5 or S-6 alien through which this alien obtained S classification through has abided by all terms, conditions of the S classification, and is recommended for adjustment. Other Comments: Signature Name Title Date (mm/dd/yyyy) Form I-854B 03/13/15 N Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Certifications (continued) Office Name and Mailing Address Office Name Street Number and Name City or Town Apt. Ste. Flr. State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address For U.S. Citizenship and Immigration Services Use Only Adjustment Granted Signature Name Adjustment Denied Date (mm/dd/yyyy) Title Office Contact Mailing Information Office Name Street Number and Name City or Town Apt. Ste. Flr. State ZIP Code Office Contact Information Daytime Telephone Number Fax Number E-mail Address Form I-854B 03/13/15 N Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com