Fillable Printable Form I-854B
Fillable Printable Form I-854B
Form I-854B
Form I-854B 07/13/17 N Page 1 of 4
USCIS
Form I-854B
OMB No. 1615-0046
Expires 07/31/2019
Inter-Agency Alien Witness and
Informant Adjustment of Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
Part 1. To Be Completed By Law Enforcement Agencies (See instructions for specific information.)
Name of Law Enforcement Agency (LEA)/Requestor
Requesting Agent (Special Agent in Charge, Chief of Police, etc.)
Control Agent
In the space below, provide all the requested information for the alien for which adjustment of status
is requested.
START HERE - Type or print in black ink.
Mailing Address
City or Town State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Contact Information
Family Name (Last Name) Given Name (First Name) Middle Name
Family Name (Last Name) Given Name (First Name) Middle Name
City or Town State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Current Location of Alien (City, State)
S-Visa Number
2.
3.
4.
5.
1.
A. Alien's Current Legal Name (do not provide a nickname)
B. Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable)
Mailing AddressC.
Other InformationD.
Alien Registration Number
(A-Number) (if any) Form I-94 Number
Passport Number
Travel Document Number
E-mail Address
Daytime Telephone Number Fax Number
Form I-854B 07/13/17 N Page 2 of 4
Place of Birth
Marital Status
Divorced
Married
Widowed
Never Married
Separated
Female
Gender
Male
Class of Admission
Date of Birth (mm/dd/yyyy)
Current Immigration Status
Country of Origin
Country of Citizenship or Nationality
Occupation Select all documents attached:
Form G-325
Form FD-258 Photos
Part 1. To be completed by Law Enforcement Agencies (continued)
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
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
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.
Other Information (continued)D.
Place of Last Entry into the U.S. (City, State)
Country of Issuance for Passport or Travel
Document
Date of Last Entry into the U.S.
(mm/dd/yyyy)
Expiration Date for Passport or
Travel Document (mm/dd/yyyy)
Form I-854B 07/13/17 N Page 3 of 4
The Department of Justice, Criminal Division (Assistant Attorney General) Certifications
, has -
If S-5:
If S-6:
If S-5, S-6, or S-7:
Supplied the information that formed the basis of entry.
Abided by all terms and conditions of the S classification.
Substantially contributed information to the success of an authorized criminal investigation or the prosecution of
an individual as per terms of entry.
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.
I certify that the alien,
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.
Abided by all specific 22 U.S.C. 2708(a) limitations of the S classification.
Received a reward under section 36(a) of the State Department Basic Authorities Act of 1956.
Other Comments:
Name
Signature
Date (mm/dd/yyyy)
Title
Office Contact Information
Part 2. Certifications (continued)
Supplied the information that formed the basis of entry.
If S-7:
E-mail Address
Daytime Telephone Number Fax Number
Office Name and Mailing Address
City or Town State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Form I-854B 07/13/17 N Page 4 of 4
Adjustment Granted Adjustment Denied
Name
Date (mm/dd/yyyy)
Title
Signature
Office Contact Mailing Information
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
E-mail Address
Daytime Telephone Number Fax Number
For U.S. Citizenship and Immigration Services Use Only
Part 2. Certifications (continued)
Office Name and Mailing Address
City or Town
State ZIP Code
Street Number and Name
Flr.Ste.Apt.
Office Name
Office Contact Information
E-mail Address
Daytime Telephone Number Fax Number
