Form I-918 Supplement B 04/24/2019Page 1 of 5 For USCIS Use Only Supplement B, U Nonimmigrant Status Certification Department of Homeland Security U.S. Citizenship and Immigration Services Page 1 of 5 START HERE - Type or print in black or blue ink. Part 1. Victim Information Agency Address Other Agency Information Part 2. Agency Information2.a.Family Name (Last Name) 2.b.Given Name (First Name) 2.c.Middle NameOther Names Used (Include maiden names, nicknames, and aliases, if applicable.)4.5.GenderMale Female 1.Name of Certifying Agency5.a.5.c.5.d.5.g.5.h.5.i.5.b.Street Number and NameCity or TownState5.f.ZIP Code Ste. Flr. Apt. Province Postal Code Country7.6. 9.Case Status OtherOn-going Completed State FederalLocal Agency Type8. RemarksDate of Birth (mm/dd/yyyy)3.a.Family Name (Last Name) 3.b.Given Name (First Name) 3.c.Middle Name10. Law Enforcement Prosecutor JudgeOther Case NumberCertifying Agency Category FBI Number or SID Number (if applicable)Alien Registration Number (A-Number) (if any)1.A-If you need extra space to provide additional names, use the space provided in Part 7. Additional Information.USCIS Form I-918 OMB No. 1615-0104 Expires 04/30/2021 3. Title and Division/Office of Certifying Official2.a.Family Name (Last Name) 2.b.Given Name (First Name) 2.c.Middle Name4.a.Family Name (Last Name) 4.b.Given Name (First Name) 4.c.Middle NameName of Certifying Official Name of Head of Certifying Agency American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement B 04/24/2019Page 2 of 5 Did the criminal activity violate a Federal extraterritorial jurisdiction statute?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)False ImprisonmentAbductionAbusive Sexual ContactBlackmailDomestic ViolenceExtortion Felonious AssaultFemale Genital MutilationIncestMurderAttempt to Commit Any of the Named Crimes Sexual AssaultObstruction of JusticePeonagePerjuryProstitutionRapeSexual ExploitationTortureTraffickingUnlawful Criminal RestraintWitness TamperingSlave TradeStalkingProvide the dates on which the criminal activity occurred.2.a.Date (mm/dd/yyyy)2.d.Date (mm/dd/yyyy)2.c.Date (mm/dd/yyyy)2.b.Date (mm/dd/yyyy)If you answered "Yes," provide the statutory citation providing the authority for extraterritorial jurisdiction.Briefly describe the criminal activity being investigated and/or prosecuted and the involvement of the petitioner named in Part 1.240 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.6. Yes No5.b.3.List the statutory citations for the criminal activity being investigated or prosecuted, or that was investigated or prosecuted. Part 3. Criminal Acts5.a. If you need extra space to complete this section, use the space provided in Part 7. Additional Information.If you answered "Yes," where did the criminal activity occur?4.b. KidnappingManslaughter Fraud in Foreign Labor Contracting Conspiracy to Commit Any of the Named Crimes Involuntary Servitude Solicitation to Commit Any of the Named Crimes4.a. Yes NoDid the criminal activity occur in the United States (including Indian country and military installations) or the territories or possessions of the United States?Being Held Hostage American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement B 04/24/2019Page 3 of 5 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?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. Yes No3. Yes NoHas 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?2.Does the victim possess information concerning the criminal activity listed in Part 3.? Yes No Part 4. Helpfulness Of The Victim 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. American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement B 04/24/2019Page 4 of 5 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? Part 5. Family Members Culpable In Criminal Activity Yes NoIf 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.)1.2.a.Family Name (Last Name) 2.b.Given Name (First Name) 2.c.Middle NameRelationship2.d.Involvement2.e. 3.a.Family Name (Last Name) 3.b.Given Name (First Name) 3.c.Middle NameRelationship3.d.Involvement3.e. 4.a.Family Name (Last Name) 4.b.Given Name (First Name) 4.c.Middle NameRelationship4.d.Involvement4.e. Part 6. CertificationI 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.Signature of Certifying Official (sign in ink) 2.1.Date of Signature (mm/dd/yyyy)Fax Number4.Daytime Telephone Number3. American LegalNet, Inc. www.FormsWorkFlow.com Form I-918 Supplement B 04/24/2019Page 5 of 5 Part 7. Additional Information4.d. 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. Petitioner's Name2.a.Agency Name1.Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name4.a.Page Number4.b.Part Number4.c.Item Number 5.d.5.a.Item Number6.c.Part Number6.b.Page Number6.a.Page Number5.b.Part Number5.c.Item Number6.d.3. A-Number (if any) A- American LegalNet, Inc. www.FormsWorkFlow.com