Supplement B, Delaration of Law Enforcement Officer for Victim of Trafficking in Persons Department of Homeland Security U.S. Citizenship and Immigration Services Sex trafficking in which a commercial sex act was induced by force, fraud, or coercion.240 Sex trafficking means the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act.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. Local Agency Address - Street Number and Name Middle Name (if any) Given Name (First Name) Family Name (Last Name) Other Names Used (include maiden name/nickname) Name of Certifying Official Title and Division/Office of Certifying Official Social Security # (if known) Suite Number City State/Province Zip/Postal Code Daytime Phone # (area code and/or extension) Fax # (with area code) Part B.240 Agency Information PART A.240 Victim Information MaleGender Female Date of Birth (mm/dd/yyyy) Name of Certifying Agency Agency Type State Federal Case Status Completed On-going Local Certifying Agency Category Law Enforcement Judge Prosecutor Other FBI or SID Number (if applicable) Case Number A # (if known)1. The applicant is or has been a victim of a severe form of trafficking in persons.240 Specifically, he or she is a victim of: (Check all that apply.240 Base your analysis on the practices to which the victim was subjected rather than on the specific violations charged, the counts on which convictions were obtained, or whether any prosecution resulted in convictions.240 Note that the definitions that control this analysis are not the elements of criminal offenses, but are those set forth at 8 CFR 214.11(a).) Part C.240240Statement of Claim Sex trafficking and the victim is under the age of 18. For USCIS Use Only Remarks Returned Date Resubmitted Reloc Sent Reloc Rec'd Receipt Date Date Date Date Date Date DateUSCIS Form I-914 OMB No. 1615-0099 Expires 04/30/2021 Page 1Form I-914, Supplement B 04/15/19 (USPS ZIP Code Lookup ) American LegalNet, Inc. www.FormsWorkFlow.com The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery. Not applicable. Other, specify on attached additional sheets.2. Please describe the victimization upon which the applicant's claim is based and identify the relationship between that victimization and the crime under investigation/prosecution. Attach the results of any name or database inquiry performed in the investigation of the case, as well as any relevant reports and findings. Include relevant dates, etc. Attach additional sheets, if necessary.3. Has the applicant expressed any fear of retaliation or revenge if removed from the United States? If yes, explain. Attach additional sheets, if necessary. Date (mm/dd/yyyy)4. Provide the date(s) on which the acts of trafficking occurred. 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) Part C.240240Statement of Claim (Continued) Page 2Form I-914, Supplement B 04/15/19 American LegalNet, Inc. www.FormsWorkFlow.com Part E.240240Family Members Implicated In Trafficking Part F.240240Attestation No YesAre 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 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 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. Date (mm/dd/yyyy)Signature of Law Enforcement Officer (identified in Part B) (sign in ink) Date (mm/dd/yyyy)Signature of Supervisor of Certifying Officer (sign in ink) Printed Name of Supervisor Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (Explain below.) Has not been requested to assist in the investigation/prosecution of any crime of trafficking. Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (Explain below.) Other, specify on attached additional sheets. Has not yet attained the age of 18.The applicant: Part D.240240Cooperation of Victim (Attach additional sheets, if necessary) Page 3Form I-914, Supplement B 04/15/19 American LegalNet, Inc. www.FormsWorkFlow.com