Inter-Agency Alien Witness and Informant Record 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-854A 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.) Control Agent Mailing Address Street Number and Name City or Town 4. Contact Information Daytime Telephone Number 5. Select all applicable boxes. As a result of providing information, the alien will be placed in danger: The alien poses no danger to people or property of the United States. If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish. Investigation. 6. Prosecution. United States Attorney involvement. Type of Requests. (Attach legal basis for request.) S-5 S-6 S-7 Consular post at which visa will be sought: in the United States or abroad. Fax Number E-mail Address Apt. Ste. Flr. State ZIP Code NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of the request, and any bargain the LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding security precautions. 7. In the space below, provide all the requested information for the alien for whom an S classification 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 Form I-854A 03/13/15 N Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 1. To be completed by Law Enforcement Agencies (continued) 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 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 Travel Document Number 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) Country of Citizenship or Nationality Female Never Married Separated Form G-325 Divorced Widowed Photos Select all documents attached: Form FD-258 8. You must provide the following information for each alien named in Item Number 7. A. Has the alien ever committed, ordered, incited, assisted, or otherwise participated in genocide; the use, conscription, or recruitment of a child soldier; Nazi persecution; or while outside of the United States, committed torture or extrajudicial killing? If "Yes," explain below. Yes No Form I-854A 03/13/15 N Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com B. For the above named alien, I request waivers for any grounds of inadmissibility that may exist. Below is a non-exhaustive list for possible grounds of inadmissibility. Refer to INA 212(a) for a complete list. (Specify all individual events in which the above named alien was arrested, cited, charged, indicted, convicted, fined or imprisoned, or for which the alien has committed, but did not have involvement with any law enforcement entity.) Crime involving moral turpitude [212(a)(2)(A)(I)] International child abduction [212(a)(10)(C)] Multiple criminal convictions [212(a)(2)(B)] Engage in unlawful commercialized vice [212(a)(2)(D)] Involved in espionage, sabotage or laws relating to technology [212(a)(3)(A)(i)] Coming to overthrow the U.S. Government [212(a)(3)(A)(iii)] Money laundering [212(a)(2)(I)] Previously removed-aggravated felony [212(a)(9)(A)(i)] Nonimmigrant without a valid passport or visas [212(a)(7)(B)(ii)] Previously excluded and deported or removed [212(a)(9)(A)] Alien smuggler [212(a)(6)(E)] Convicted of law pertaining to controlled substance [212(a)(2)(A)(i)(II)] Prostitute and/or procurer of prostitution [212(a)(2)(D)] Unlawful activity related to national security [212(a)(3)(A)] Terrorist activities [212(a)(3)(B)] Communist Party member [212(a)(3)(D)] Fraud/Misrepresentation [212(a)(6)(C)(i)] Immigrant without a visa [212(a)(7)] Human trafficking [212(a)(2)(H)] Ordered, incited, assisted or otherwise participated in the commission of acts of torture or extra judicial killing [212(a)(3)(E)] Controlled substance trafficker [212(a)(2)(C)] Engaged in conduct relating to severed violations of religious freedoms [212(a)(2)(G)] Drug abuser or addict [212(a)(1)(A)(iv)] Other No waivers are requested/needed C. Briefly explain below each ground of inadmissibility you selected or other grounds of inadmissibility not included in the list above. If you need extra space to complete this item, attach a separate sheet of paper; type or print the alien's name and 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. Form I-854A 03/13/15 N Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Certifications Alien Certification (S classification request) I certify under penalty of perjury that I have reviewed with the LEA all the information in Part 1., disclosed all information to the best of my ability, and disclosed all reasons for which I may be inadmissible to the United States or for which I may be removed from the United States; that I shall report at least every three months my whereabouts and activities as the LEA shall require; that I understand I am subject to removal for any grounds of inadmissibility (conduct or condition) or removability not disclosed at this time or for conduct committed after admission to the United States; that I shall abide by all conditions, limitations, and restrictions imposed upon my entry; that the classification I seek is temporary and will terminate within three years; that I am restricted by the terms of my admission to very specific means by which I will be able to remain permanently in the United States; that