Form I-918 04/24/19 Page 1 of 11 To be completed by an attorney or accredited representative (if any). START HERE - Type or print in black or blue ink. Part 1. Information About You (Person filing this petition as a victim)1.a.Family Name (Last Name) 1.b.Given Name (First Name) 1.c.Middle Name Safe Mailing Address (if other than Home Address)Street Number and Name4.b.4.d.City or Town4.e.State4.f.ZIP Code4.c. Ste. Flr. Apt. Street Number and Name3.a.3.c.City or Town3.d.State3.e.ZIP Code3.b. Ste. Flr. Apt. Home Address In Care Of Name Other Names Used (Include maiden name, nicknames, and aliases, if applicable) 2.a.Family Name (Last Name) 2.b.Given Name (First Name) 2.c.Middle Name 4.a.Province 4.g.Postal Code4.h. 4.i.Country For USCIS Use Only Action BlockReceipt U.S. Embassy Consulate Validity Dates (mm/dd/yyyy) To: / / / From: / / /Wait Listed Stamp Number Date (mm/dd/yyyy)Remarks3.f.Postal Code3.g.Province 3.h.Country Alien Registration Number (A-Number) (if any)6.USCIS Online Account Number (if any)7.5.A-U.S. Social Security Number (if any) Other Information Married SingleDivorced Marital StatusWidowed8. USCIS Form I-918 OMB No. 1615-0104 Expires 04/30/2021 Petition for U Nonimmigrant Status Department of Homeland Security U.S. Citizenship and Immigration ServicesAttorney or Accredited Representative USCIS Online Account Number (if any)Attorney State Bar Number (if applicable)Select this box if Form G-28 is attached. (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 04/24/19 Page 2 of 11 I am under 16 years of age.I am submitting Form I-918, Supplement B, U Nonimmigrant Status Certification, from a certifying official.I possess information concerning the criminal activity of which I was a victim. Part 1. Information About You (continued)12.15.17.16.18.19.a.19.b.20.1.2.3.4.5.6.7.a. Yes No Yes No Yes No Yes No Yes No Yes NoSelect "Yes" or "No," as appropriate, for each of the following questions.I was or am in immigration proceedings.The crime of which I am a victim occurred in the United States (including Indian country and military installations) or violated the laws of the United States.I have suffered substantial physical or mental abuse as a result of having been a victim of this criminal activity.I am a victim of criminal activity listed in the INA at section 101(a)(15)(U)(iii).11.Date of Issuance for Passport or Travel Document (mm/dd/yyyy)Form I-94 Arrival-Departure Record NumberPassport NumberTravel Document Number Country of Issuance for Passport or Travel Document Expiration Date for Passport or Travel Document (mm/dd/yyyy)13. Country of Citizenship or Nationality14.Country of Birth Date of Last Entry into the United States (mm/dd/yyyy)22. Place and Date of Last Entry into the United States and Date Authorized Stay ExpiredCurrent Immigration Status7.c.Exclusion Date (mm/dd/yyyy) Exclusion ProceedingsRemoval Date (mm/dd/yyyy) Removal Proceedings7.b.If you answered "Yes," select the type of proceedings. If you were in proceedings in the past and are no longer in proceedings, provide the date of action. If you are currently in proceedings, type or print 223Current224 in the appropriate date field. Select all applicable boxes. Use the space provided in Part 8. Additional Information to provide an explanation. Part 2. Additional Information About YouAnswering 223Yes224 to the following questions below requires explanations and supporting documentation. Attach relevant documents in support of your claims that you are a victim of criminal activity listed in the Immigration and Nationality Act (INA) section 101(a)(15)(U)(iii). You must also attach a personal narrative statement describing the criminal activity of which you are a victim. If you are only petitioning for U derivative status for qualifying family members subsequent to your (the principal petitioner) initial filing, you are not required to submit evidence supporting the original petition with the new Form I-918. Rescission Proceedings7.e.Judicial Date (mm/dd/yyyy)7.f.Rescission Date (mm/dd/yyyy) Judicial Proceedings Deportation ProceedingsDeportation Date (mm/dd/yyyy)7.d.10.Date of Birth (mm/dd/yyyy) 9.GenderMale Female If you need extra space to complete Part 2., use the space provided in Part 8. Additional Information.State City or Town 21.Date Authorized Stay Expired (mm/dd/yyyy) No Yes American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 04/24/19 Page 3 of 119.a. 10.c.Date of Entry (mm/dd/yyyy)10.b.Status at the Time of Entry (for example, F-1 student, B-2 tourist, entered without inspection)10.d.City or Town 10.a.City or Town 9.c.9.d.Status at the Time of Entry (for example, F-1 student, B-2 tourist, entered without inspection)9.b.Date of Entry (mm/dd/yyyy) Part 2. Additional Information About You (continued)If you are outside of the United States, provide the U.S. Consulate or inspection facility or a safe foreign mailing address you want notified if this petition is approved. Pre-Flight Inspection U.S. ConsulateType of Office (Select only one box):Port-of-Entry 11.a. State State Place of Entry into the United StatesPlace of Entry into the United StatesCity or Town 8.c.8.d.8.b. Status at the Time of Entry (for example, F-1 student, B-2 tourist, entered without inspection)State Place of Entry into the United StatesSafe Foreign Address Where You Want Notification Sent (if other than U.S. Consulate, Pre-Flight Inspection, or Port-of-Entry)12.c.City or Town12.d.Postal Code12.e.Province12.f.CountryStreet Number and Name12.a.12.b. Ste. Flr. Apt. Part 3. Processing InformationAnswer the following questions about yourself. For the purposes of this petition, you must answer "Yes" to the following questions, if applicable, even if your records were sealed or otherwise cleared or if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. NOTE: If you answer 223Yes224 to ANY question in Part 3., provide an explanation in the space provided in Part 8. Additional Information. NOTE: Answering "Yes" does not necessarily mean that U.S. Citizenship and Immigration Services (USCIS) will deny your Petition for U Nonimmigrant Status.Been arrested, cited, or detained by any law enforcement officer (including Department of Homeland Security (DHS), former Immigration and Naturalization Service (INS), and military officers) for any reason?Committed a crime or offense for which you have not been arrested?1.a.1.b. Yes No Yes NoHave you EVER:Been charged with committing any crime or offense?Been convicted of a crime or offense (even if the violation was subsequently expunged or pardoned)?1.d.1.c. Yes No Yes No11.d.11.b.11.c.City or Town State Country Been placed in an alternative sentencing or a rehabilitative program (for example, diversion, deferred prosecution, withheld adjudication, deferred adjudication)?1.e. Yes No Provide the date of entry, place of entry, and status under which you entered the United States for each entry during the five years preceding the filing of this petition.8.a.Date of Entry (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 04/24/19 Page 4 of 11Received a suspended sentence, been placed on probation, or been paroled?1.f. Yes No Part 3. Processing Information (continued) Outcome or disposition (for example, no charges filed, charges dismissed, jail, probation)Where were you arrested, cited, detained, or charged?2.c.2.f.Country 2.d.City or Town 2.e.State Why were you arrested, cited, detained, or charged? 2.aDate of arrest, citation, detention, or charge (mm/dd/yyyy)2.b.Information About Arrests, Citations, Detentions, or ChargesExercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?1.i. Yes NoBeen in jail or prison?Been the beneficiary of a pardon, amnesty, rehabilitation, or other act of clemency or similar action?1.g.1.h. Yes No Yes No Outcome or disposition (for example, no charges filed, charges dismissed, jail, probation)Why were you arrested, cited, detained, or charged? Where were you arrested, cited, detained, or charged?3.a3.c.Date of arrest, citation, detention, or charge (mm/dd/yyyy)3.b.3.f.Country 3.d.City