Supplement B, Delaration of Law Enforcement Officer for

Supplement B, Delaration of Law Enforcement Officer for Victim of Trafficking in Persons Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-914 OMB No. 1615-0099 Expires 12/31/2023 START HERE - Type or print in ink. This form should be completed by Federal, state, local, or tribal law enforcement agencies for victims under the Victims of Trafficking and Violence Protection Act (VTVPA). Public Law 106-386. as amended. PART 1. Victim Information 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Other Names Used 3. 5. 6. Provide any other names you have used since birth, including aliases, maiden names, and nicknames. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (ddirrun/yyyy) 4. Gender or Sex El Male El Female El Other Alien Registration Number (A-Number) (if any) P. A- U.S. Social Security Number (SSN) (if any) .r Part 2. Agency Information 1. Name of Certifying Agency Federal Bureau of Investigations 2. Name of Certifying Official 3. Title of Certifying Official 4. Division/Office of Certifying Official 5. Agency Mailing Address Street Number and Name For USCIS Use Only Returned Date Date Resubmitted Date Date Reloc Sent Date Date Reloc Rec'd Date Date Receipt Remarks 26 Federal Plaza City or Town (ILSPI VP rode Lank -A Apt. Ste. Flr. Number 0 0 El State ZIP Code NY New York 6. Daytime Telephone Number 7. Fax Number 102711 Form 1-914. Supplement B Edition 12/C0/21 Page I EFTA00156636 Part 2. Agency Information (continued) 8. Agency Type El Federal El State ID Local El Tribal 9. Case Status El On-going El Completed 10. Certifying Agency Category El Judge El Law Enforcement El Prosecutor El Other 11. Case Number 12. FBI or SID Number Part 3. Statement of Claim 1. The applicant is or has been a victim of a severe form of trafficking in persons. Specifically, he or she is a victim of: (Select all that apply. Base your analysis on the victimization the applicant experienced rather than on the specific violations charged. the counts on which convictions were obtained, or whether any prosecution resulted in convictions. 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).) Sex trafficking in which a commercial sex act was induced by force, fraud, or coercion. Sex trafficking means the K recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act. K Sex trafficking and the victim is under 18 years of age. h7i The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, =I fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery. K Other, specify on attached additional sheets. 2, Please describe the victimization the applicant's claim is based on and identify the relationship between that victimization and the crime investigated or prosecuted. 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. Applicant was recruited, harbored, and obtained by Jeffrey Epstein and others for purposes of sexual slavery. On numerous occasions, Jeffrey Epstein coerced, threatened, and forced Applicant into submission for purposes of him committing sex acts with or unto her. Applicant shared pictures of injuries she sustained as a result of sex acts Mr. Epstein's subjected her to. 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. licant informed us that she and some of her , directly and indirectly, have received threats during Applicant's participation in the investigation and prosecution of criminal charges against suspects/defendants Jeffrey Epstein and Ghislaine Maxwell. Applicant expressed fear of retaliation or revenge by individuals connected to or implicated in the alleged criminal acts of Mr. Epstein and Ms. Maxwell. Applicant has expressed fear of serious harm by such individuals if she were to be removed from the United States. Form 1-914. Supplement B Edition 12/02/21 Pu 2 EFTA00156637 4. Provide the date(s) on which the acts of trafficking occurred. Date (mm/dd/yyyy) 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. 18 DSC 371; 18 DSC 1591(a), (b); 18 DSC 1623; DSC 2423(a); NYPL 130.55 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. Date (mm/dd/yyyy) 06/28/2022 A. Item it., provide an explanation below in Item Number 2.) B. n Has failed to comply with requests to assist in the investigation/prosecution of the crime of trafficking. (If you select " Item B., provide an explanation below in Item Number 2.) C. 0 Has not been requested to assist in the investigation/prosecution of any crime of trafficking. D. 0 Has not yet attained the age of IS. E. 0 Other, specify on attached additional sheets. 2. If you selected Item A. or Item B. above, provide an explanation for your selection. participated in several telephonic and in person meetings with our office concerning our invests ation of criminal charges against Jeffrey Epstein and Ghislaine Maxwell. Ms. responded to questions asked of her about alleged criminal activities by Mr. Epstein and Ms. Maxwell. I. The applicant: z Has complied with requests for assistance in the investigation/prosecution of the crime of trafficking. (If you select Part 5. Family Members Implicated In Trafficking 1. Are any of the applicant's family members believed to have been involved in his or her trafficking to the UnitedStateses? oy No If you answered "Yes" to Item Number 1.. list the relative(s) and describe the involvement. Attach additional sheets if necessary. Full Name Relationship Imokement N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Form -914. Supplement B Edition 12/02/21 Page 3 EFTA00156638 Part 6. Attestation 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 (USCIS), based upon this certification. I further certify that if the victim refuses to comply with reasonable requests for assistance in the investigation or prosecution of the acts of trafficking of which he/she is a victim, I will notify USCIS. 1. Signature of Law Enforcement Officer (identified in Part 2.) 2. Signature of Supervisor of Certifying Officer 3. Printed Name of Supervisor Date of Signature (min/dd/yyyy) Date of Signature (mm/cld/yyyy) Form 1-914. Supplement B Edition 12/02/21 Page 4 EFTA00156639