EFTA Document EFTA01699742

a EFTA01699742 U.S. Department of Justice United States Attorney Southern District of New York The Silvio J. Mono Building One Saint Andrew} Plcca New York New York 10007 June 15,2020 BY FAX lo= To whom it may concern: Please be advised that the accompanying grand jury subpoena has been issued in connection with an official criminal investigation of a suspected felony being conducted by a federal grand jury. The Government hereby requests that you voluntarily refrain from disclosing the existence of the subpoena to any third party. While you are under no obligation to comply with our request, we are requesting you not to make any disclosure in order to preserve the confidentiality of the investigation and because disclosure of the existence of this investigation might interfere with and impede the investigation. If you intend to disclose the existence of this Grand Jury Subpoena request to a third party, please let me know before making any such disclosure. Thank you for your cooperation in this matter. By: Sincerely, GEOFFREY S. BERMAN United States Attorney "A_ - - Assistant United States Attorney Telephone: EFTA01699743 INIIMms. EFTA01699744 Grand Jury Subpoena PnitetroStatesPiztrict Court SOUTHERN DISTRICT OF NEW YORK TO: AT&T Wireless Legal Compliance 11760 Highway 1, Suite 600 North Palm Beach, FL 33408 GREETINGS: WE COMMAND YOU that all and singular business and excuses being laid aside, you appear and attend before the GRAND JURY of the people of the United States for the Southern District of New York, at the United States Courthouse, 40 Foley Square, Room 220, in the Borough of Manhattan, City of New York, New York, in the Southern District of New York, at the following date, time and place: Appearance Date: July 6, 2020 Appearance Time: 10:00 a.m. to testify and give evidence in regard to an alleged violation of : 18 U.S.C. §§ 1591, 1594(c), 2423(a), 2422(b) and not to depart the Grand Jury without leave thereof, or of the United States Attorney, and that you bring with you and produce at the above time and place the following: See Attached Rider Personal appearance is not required if the uested records are (1) roduced by on or before the return date to Special Agent , telephone: or via email at ; and (2) accompanied by an executed copy of the attached Declaration of Custodian of Records. PLEASE PROVIDE IN ELECTRONIC FORMAT IF POSSIBLE. Failure to attend and produce any items hereby demanded will constitute contempt of court and will subject you to civil sanctions and criminal penalties, in addition to other penalties of the Law. DATED: New York, New York June 15, 2020 GEOFF E .GERMAN United States Attorney for the Southern District ofNew York Assistant United States Attorney One St. Andrew's Plaza New York, New York 10007 Telephone: EFTA01699745 RIDER (Grand Jury Subpoena to AT&T. dated June 15. 2020) Please provide any and all records (including, but not limited to, incoming and outgoing calls with any call details, local and long distance usage details, all subscriber opening and/or registration documents, all subscriber identification and contact information, all subscriber billing and payment information, SMS/text messaging records, IP history and login records, associated email addresses and/or screen names, and any additional accounts associated with any of the below-listed names, identifiers, addresses, phone numbers, and accounts listed and associated records for those accounts) relating to the following telephone numbers, as listed below, for the time period of March I, 2020 to the present: • N.B.: Personal appearance is not required if the requested records are (1) produced by on or before the return date to Special , telephone: or via email at and (2) accompanied by an executed copy of the attached Declaration of Custodian of Records. PLEASE PROVIDE IN ELECTRONIC FORMAT IF POSSIBLE. IMPORTANT: REQUEST FOR NON-DISCLOSURE Due to the ongoing nature of the investigation, it is requested that you do not disclose any information relating to this Crand Jury subpoena request to any third party. EFTA01699746 Declaration of Custodian of Records Pursuant to 28 U.S.C. § 1746, I, the undersigned, hereby declare: My name is (name of declarant) I am a United States citizen and I am over eighteen years of age. I am the custodian of records of the business named below, or I am otherwise qualified as a result of my position with the business named below to make this declaration. I am in receipt of a Grand Jury Subpoena. dated June 15, 2020. and signed by Assistant United States Attorney . requesting specified records of the business named below. Pursuant to Rules 902(1 I) and 803(6) of the Federal Rules of Evidence, I hereby certify that the records provided herewith and in response to the Subpoena: (1) were made at or near the time of the occurrence of the matters set forth in the records, by, or from information transmitted by, a person with knowledge of those matters; (2) were kept in the course of regularly conducted business activity; and (3) were made by the regularly conducted business activity as a regular practice. I declare under penalty of perjury that the foregoing is true and correct. Executed on (date) (signature of declarant) (name and title of declarant) (name of business) (business address) Definitions of terms used above: As defined in Fed. R. Evid. 803(6), "record" includes a memorandum, report, record, or data compilation, in any form, of acts, events, conditions, opinions, or diagnoses. The term, "business" as used in Fed. R. Evid. 803(6) and the above declaration includes business, institution, association, profession, occupation, and calling of every kind, whether or not conducted for profit. EFTA01699747 r SEE REVERSE SIDE FOR F LW HER NS'RuCTIONS PERSONAL IDENTIFICATION L INFORM/G:0N IN BLACK LAS NAM FIRST NAME MIDDLE MME FIN LEAVE BLANK F0443 (R 4413) SIOPNWRE OF PERSON FINGEPPRNTIO RE90ENCE OF PERSCN RPRIPITEO •tigrom BE NOTWIEC M CASE OF ELERGERCY ARROFTS SUBMITTED BY GATEOF SRTN DO 'Arit De, 'Ps F N N71 140 G BLN LF RAW ADORE SS Non-Federal Confidential Screening FINCER• 4 %' DUE FINGERPRICED X RAC HOT RGT EYES HAIR PLACE OF OATH Foe %CC14 SECURITY IASCELLANEOUS SO SCARS AP, LEAVE BLANK R THuia SR 6L THUMB I 7 LEFT [VA APP:414STAPIN SPAILLANCOUSt+ I I TALUS I ft PAPPAS iti]Aff co. CP4C4 RI 'WEN lativti•MOUtix EFTA01699748 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1. Use printer's ink. 2 Distribute ink evenly on inking slab 3. Wash and dry lingers thoroughly 4. Roll fingers from nail to nail, and avoid allowing lingers to shp. 5. Be sure impressions are recorded in correct order. 6. Notate in the appropriate linger blocks if applicant is missing one or more lingers for any reason. II not missing. all ten impressions must be provided with scars and deformities notated. 7. If some physical condition makes it impossible to obtain perfect impressions, submit the best that can be obtained 8. Examine the completed prints to see if they can be classified. bearing in mind the following: Most fingerprints fall into the patterns shown below Other patterns occur tnirequently and are not shown here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes. State statutes pursuant to Pub.L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary: however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained. your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated informatiorVbiometrics are retained in NGI, your information may be disclosed pursuant to your consent. and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment. contracting, licensing, security clearances, and other suitable determinations: local, state, tribal, or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety PASTE PHOTO HERE (OPTIONAL) FD-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:OW.02017 11:5138 EFTA01699749 r : EE REVERSE SIDE FOR FukTHER iNSTRuC - IONS PERSONAL IDENTIFICATION LAST NAME NAM INFORMATION IN BLACK FIRST NAME MCDI NAE/I rd LEAVE CLANK FD-3.43(Ret 94131 SIGNATURE Of IERSON FINGERPRINTED RESCENCE OF PERSON FINGERPREITED Pia NOTIFIED N CASE CF ELERGENCY FINGERPRINTS SUMAITTED BY WAG ADDEESS Non -Federal Confidential Screening FAEGERPRINTED BY DATE FIAGERPRIICE0 F W sot A't OF OREN DOB Akre) 0e As N71 140 G BLN LP RACE "GT ATSI EYES MAR RACE a SETH ROB AlEsai ISCiAnTY IESCELIAPEOUS NO SCARS AND BERES LEAVE BLANK REF LZIT rocinFINCERIVAAEN EINIAATECOvrAy R Tit*. MOTT FODA CNCEffitt TAKEN SAAA.TAASOutte EFTA01699750 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1. Use printers ink. 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly. 4. Roll fingers from nail to nail. and avoid allowing fingers to slip. 5. Bo sure impressions are recorded in correct order. 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. II not missing, all ten impressions must be provided with scars and deformities notated. 7. If some physical condition makes it impossible to obtain perfect impressions. submit the best that can be obtained. B. Examine the completed prints to see if they can be classified. bearing in mind the following: Most fingerprints fall into the patterns shown below Other patterns occur infrequentty and are not shown here PASTE PHOTO HERE (OPTIONAL) FD-3.43 (Rev. 9-9-i3) U.B. GOVERNMENT PUBLISHING OFFICE:OB/244017 I 1:53.38 FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders. and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment. licensing, and security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of Comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and. while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI. your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register. including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include. but are not limited to, disclosures to: employing, govemmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitable determinations: local, state. tribal. or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety EFTA01699751 I SEE REVERSE SCE FOR FURTHER INSTRUCTIONS PERSONAL IDENTIFICATION I ALL INFORMATION IN BLACK LIST."( NAM FIRST WAIF MICC“ AM FBI LEAVE BLANK F0-353(R•494471 IGNATURE OF PERSON FINGERPRPin0 REYLENCE CF PERSON FIHGERPRNTEO F RPRINTS Su/Uri-ED Iv DATE Of BOTH BOB ma. O., New F W N71 140 G BLN LP TO CE NOTFIED IN CASE EN£RGENC 'LOAF ANSIXESS Non-Federal Confidential Screening DATE IlsGERPRIN'E0 x I RAC At, Ens PIACE BM). ROB SOCI.LL fECWITv FIPItINTED Et LAREOUS NO SCARS Ax. CUSS LEAVE BLANK an ran r inKCIISTAXEm SikOATANCOJS0' R TtiWO EFTA01699752 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION. CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1 Use printer's ink 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly 0 Roll fingers from nail to nail, and avoid allowing fingers to slip. 5. Ete sure impressions are recorded in correct order 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. If not missing. all ten impressions must be provided with scars and deformities notated 7 If some physical condition makes K impossible to obtain perfect impressions. submit the best that can be obtained 8 Examine the completed prints to see if they can be classified. bearing in mind the following. Most fingerprints fall into the patterns shown below Other patterns occur infrequently and are not shown here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil. criminal, and latent fingerprint repositories) or other available records of the employing investigating. or otherwise responsible agency. The FBI may retain your fingerprints and associated informationlbiometrics in NCI after the completion of this application and. while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information /biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitable determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies: and agencies responsible for national security or public safety PASTE PHOTO HERE (OPTIONAL) Ft)-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:0121/2017 11:5138 EFTA01699753 I '_ EE REVERSE SIDE FOR FURTHER INSTRUCTIONS PERSONAL IDENTIFICATION INFORMATIONIABLACK rg LEAVE BLANK LAST NYE NAM FIRST NAME MCGEE NAPE FP-353 (Rev 94431 MATURE OF PERSON MGM:PROOFS PC OF PERSON FINGERMINTED PEIMVOTIFED N CASE OF MERGERS MIGERPRINTS SLORTTED BY P M N71 140 G DA OF EIRl ee.. BLN DO: 0 V... LP PUCE OF ORM RCS War ADORE SS Non-Poderal Confidential Ccroening I'm:ER/MINTED BY DATE FINGERPRINTED RACE NOT MGT EYES NAN SOME S MERRY NO ELLANEOVS NO SCARS MD MARKS LEAVE BLANK EF EFTA01699754 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerer 1. Use printer's ink. 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly. 4. Roll ringers from nail to nail, and avoid allowing fingers to slip. 5. Be sure impressions are recorded in correct order. 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. If not missing, all ten impressions must be provided with scars and deformities notated 7. II some physical condition makes it impossible to obtain period impressions, submit the best that can be obtained 8. Examine the completed prints to see if they can be classified. bearing in mind the following Most fingerprints fall into the patterns shown below Other patterns occur infrequently and are not slytian here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your applicafion, supplemental authorities include Federal statutes. State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary: however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment. licensing, and security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil. criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometncs are retained in NGI. your information may be disclosed pursuant to your consent. and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include. but are not limited to. disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting. licensing, security clearances, and other suitable determinations: local, state, tribal, or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety PASTE PHOTO HERE (OPTIONAL) FD-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:Orta4/2017 liStge EFTA01699755 Attachment A CERTIFICATION FOR CONTINUED PRESENCE BY REQUESTING LAW ENFORCEMENT AGENCY TO: Unit Chief Parole and Law Enforcement Programs Unit Homeland Security Investigations U.S. Immigration and Customs Enforcement FROM: SAC FBI, New York Field Office RE: Request for Continued Presence for: SAC of the FBI New York Field Office concur in this request and certify, in accordance with the Department of Homeland Security (DHS)'s procedures for Continued Presence, that: 1. The justification and information concerning the request for Continued Presence are accurate and complete. 2. Documentation is attached certifying that the alien is a victim of a severe form of trafficking and may be a potential witness to that trafficking. 3. Name checks have been completed in the principle law enforcement databases on the person named in the request (National Crime Information Center and any other databases available) and, as appropriate, information from foreign law enforcement agencies. Criminal history check results based on fingerprints have been received and any identification issues resolved. [For. the. FBI: Coordination.has also been effected with appropriate member agencies of theintelligence Community.' 4. Copies of all database screens on the person named above, including negative responses, have been identified and forwarded to U.S. Immigration and Customs Enforcement, Homeland Security Investigations, Parole and Law Enforcement Programs Unit. 5. No promises have been made to the Victim that he or she will remain in the United States beyond the authorized period of Continued Presence. 6. An active investigation is underway by a law enforcement agency that requires the assistance of this subject. Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01699756 Signature [of Authorizing Official] Date Printed Name [of Authorizing Official] Title [of Authorizing Official] Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01699757 DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE 1bartA: InforatatiOnon'theitiopm. N.3:7 -.72.44t''> ;a14cir iCPIAC:' 1. Name: (Last) 2. Date of Birth (mo., day, yr.) 6. Allas(es) 8. Passport Number 11. Social Security Number (First) 3. Country of Birth 6. Gender (check one) Male J Female (Middle) 4. Country of Citizenship 7. Alien Number (A#) A 9. Country of Issuance 10. Expiration Date (mo., day, yr.) 08/04/2020 & 05/14/2025 iiPartataitoguntifIgiaStieSO: 'Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: (First, Last) 2. Daytime telephone number (include area code) Ext 3. Fax number 2. Case Agent where the Victim resides (if the Victim resides In a Jurisdiction other than that of the Lead Case Agent): (First, Last) 2. Daytime telephone number 3. Fax number (include area code) Supplemental Information: Requesting Agency: Federal Bureau of Investigation Group Supervisor's name (First, Last) Daytime telephone number (includingarea code) Fax number Ext Victim-Witness Specialiat's/Coordlnator's name (First, Last) Daytime telephone number (Including area code) Fax number ext. ext. Request.for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA01699758 *Note: Please complete all information below. 1. Is the Victim currently in.the United States? El Yes O No 2. The Victim's current immigration status: In the U.S. on an E-2 Visa 3. is the Victim requesting Continued Presence based upon a pending,civil action under 18 U.S.C. § 1595? 0 Yes 0 No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? 0 Yes Ej No (if yes, where and when) City, State: 5. When did the Victim enter the United States? 1st Entry 09/0145 6. Through which Port of Entry did the Victim enter the United States? New York, New York 7. How did the Victim enter the United States? Flight oi3/40 5,1* -00,09;**000:00.111M011-0411W Please answer each question as completely as.possible (Attach additional sheet(s), if necessary.) 1. Significance and value of the Victim to this case: (please provide a brief explanation of how the Victim meets the definition of "severe forin of trafftking" under section 103(8), Victims of Trafficking end Violence Protection Act of 2000, Pub. L. No. 106-388) See attached sheet. 2. The Victim's criminal involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) No criminal convictions. 3. Risk the Victim presents to public safety and/or to national security (i.e., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary: (Attach copy of risk assessment report) No risk to public safety or national security 4. Financial responsibility for the Victim: (Please explain manner in which the Victim's living expenses will be met.) is requesting employment authorization to work in the United States. 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state; attach additional sheet(s), if necessary.) No relatives live in the United States. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA01699759 6. Is employment authorization requested? E3 Yes O No (If yes, please attach completed U.S. Citizenship and immigration Services FORM 1-765; Application for Employment Authorization, and 1-102, Application for Replacement/Initial Nonimmigrant Arrival/Departure Document) Note: Information contained in question # 7-is not required for a victim to receive Continued Presence; however, this information is required fora victim to be certified to receive benefits from the Departinent of Health and Human Services (HHS), Office of RefugeeResettlement(ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. Is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. 0 Yes O No 7404; tocation.whete the' Iiistintayinqtielde inWatktkitiiiOarIltigta Street Address City New York State NY *Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for Continued Presence must be submitted to the ICE HSI Headquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reportedto the requesting agency headquarters, which In turn will notify LEPU. The requesting agency will also notify LEPU Immediately if the alien departs the United States. gfitatt:PrOectifitatiomotRiipOtitidiRiterli Tlit-WsceggSylpiai r t3fev As the requesting agency representative, I understand that, should thls Continued Presence be granted, it is MY responsibility to follow all of the policies and procedures established by LEPU, including quarterly reporting, reporting changes in the Victim's status (Le., departure or change in status), and requesting applicable extensions of approved Continued Presence. e na ure) / Supervisory Special Agent me) gen gnature) / Special Agent (Print Name and Title) -7(lo 2-0 Date) 1 / I ES 2020 (Date) if the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (PrintRame and Title) Request for Continued Presence FOR OFFICIAL USE ONLY! LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 3 of 4 EFTA01699760 Privacy Act Statement Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form. ill be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting.law enforcement officedagentand their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared.with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted. under 5 § 552a(b) pursuant to the routine uses published in the Department of Homeland Seturity system of records notice, DHSACE-011 Immigration and Enforcement Operational Records. Disclosure: The discloture of the infortnatien on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of-the request for Continued Presence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 4 of 4 EFTA01699761 FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE PART D:1 Jeffrey Epstein abused over several years, beginning when she was 18 years old. It was during the course of this abuse that Epstein brought into some of his massages to participate in sex acts with other girls. Epstein controlled every aspect of -s life—including her physical appearance, her weight, and her clothing—for years. This controlling behavior took multiple abusive forms, including forcing to have multiple plastic surgeries, forcing her to engage in BDSM, referring to her as his "sex slave," insulting her, and physically abusing her, including by choking her and throwing her down a set of stairs. FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE EFTA01699762 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-102 OMB No. 1615-0079 Expires 10/31/2019 For. i WOO Receipt Action Block UJe. : i I :Otifr• ! New I-94 Number I . Remarks I. START HERE. Type or print in black ink iPart Inflonkationbnut tow 1. Mien Registration Number (A-Number) le A- 1 1 1 1 1 1 2. LlSaS Online Account Number (if any) FfauaTitionsg e77— 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 41.0iraitu4Spriiiiw77 4.a. In Care Of Name 4.b. Street Number and Name 4.c. Apt. 2 Ste. 0 Fir. 0 4.d. City or Town 1\16v4 o 4.e. State 4.f. ZIP Code MC*5 5. Is your current U.S. mailing address the same as your U.S. physical address? g Yes 0 No If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.1. 1 1 La. In Care Of Name To Be Completed by an Attorney or Aerredited Representative, if any. K Select this box if Form G-28 is attached to represent the applicant. Attorney State License Number Lb. Street Nut and Name 6.c. Apt. 0 Ste. 0 FIr. 0 6.d. City or Town 6.e. State 6L ZJI)Code erinformation 7. Date of Birth (mm/dd/yyyy) ► 8. Country of Birth 9. 10. . titer (if any) Entry Inforentizt0th 11. Dale of Last Batty into the United States (nnliddiTRY) ► 12. Place of Last Entry Into the United States (City and State) LDS *N66LES , CA. Form I-102 10/19/17 N Page 1 of 4 EFTA01699763 Part k., Ihformition About You 0.0116=4 I3. Current Nonimmigrant Status E 2 VI5ft 14. Date Status Expires (mmidd/yyyy) ► 15.a. Form 1-94,1-94W, o 15.b. Passport Number 15.c. Travel Document Number 15.d. Coun of Issuance for Passport or Travel Document 15.e. Expiration Date for Passport or T . (mrnidd/yyyy) 03125/202.1 Reason ior Applrcation • Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) La. 1.b. O I am applying to replace my lost or stolen Form I-94 or I.94W. K I am applying to replace my lost or stolen Form I-95. Lc. K I am applying to replace my Form I-94 or I-94W because it was mutilated. I have attached my original Form I-94 or I-94W. 1.d. O lam applying to replace my Form 1-95 because it was If you are unable to provide the original of your Form I-94, mutilated. I have attached my original Form I-95. I-94W, or 1-95, provide the following information: to. Ei I was not issued Form I-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form I-94, CBP at a port-of-entry in the United States (whether I-94W, or I-95. at a land border, airport, or seaport). 3.a. Family Name 1.f. El I was issued Form 1-94,1-94W, or I-95 with incorrect (Last Name) infommtion, and I am requesting that USCIS correct the document I have attached my original FormI-94, 1-94W, or 1-95. 3.b. Given Name (First Name) 3.c. Middle Name Lg. O I was not issued Form I-94 when I entered as a nonimmigrant member of the military, and I am filing this application for an initial Form I-94. 4. Class of Admission at Last Entry into the United States E 5. Place of Last Entry into the United States (City and State) OartJ: :Pro- cessing Information . La. Are you filing this application with any other petition or application? O Yes g No If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number Lb. Lb. USCIS Form Number and Name 2.a. Are you now in removal proceedings? O Yes g No If "Yes" complete Item Number 2.b. Lb. Provide detailed information regarding the proceedings. If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper, indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. NG\N -PRsspoe-c- Ey laNetk0NI LDS Mll e L6S Form I-102 10/19/17 N Pogo 2 of 4 EFTA01699764 -.Taii.4 Stateinent,tlitirlOafiOns;Sitiiiiiiiiiarid. : :skulitqtjfifOrm4tion,Altke MIppliMpff, NOTE: Select the box for either Item Number la. or 1.b. If applicable, select the box for Item Number 2. 1.a. tgi I can read and understand English, and have read and . _ _ Interpreter's Pull Nome Provide the following information concerning the interpreter: understand every question and instruction on this form, as well as my answer to every question. 1.a. Interpreter's Family Name (Last Name) Lb. O The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) !Part $: Contact I4formtititin,Certifidatioii, and, Signature of the Interpreter a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and:have provided true and correct responses in the language indicated above. 2. O I have requested the services of and consented.to who is O is not 0 an attorney or accredited representative, preparing this form for me. ',241plicturt Cog:main: I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immi 3.a. Applicant's Signature 4 3.b. Date of Signature (mm/dd/yyyy) ► ,Applicant's Contact InformatiO4 4. A icant's o Telephone Number 5. 4 obile Tele hone Number /Pt /2_012.6 Intelpretet!s Moiling &Ideas, 3.a. Street Number and Name 3.b. Apt. O Ste. O Flr. 3.e. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country — . int'cripnet.fr.Ss•Cortgtetirtforingthit 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address Fox= I-102 10/19/17 N Page 3 of 4 EFTA01699765 Part 5. Contact Information, Certification, and Signature of the Interpreter(continued) Interpreter Certification I certify that: I am fluent in English and ,which is the same language provided in Part 4., Item Number I.b.; I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number I.bz; and The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy) ► Part ,66 Contact Information', litiatationvnadi ISignaturnof ',the Person Preparing this Application,,It Other than the Applicant „__. Preparer's PIO fh.7ame _ . Provide the following information concerning the preparer: la. P r's Family Name, Last Naps) 1.b. parefs Given Name (First Name) 2. Preparers Business or Organization Name fs 'Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. 0 Ste. 3.c. City or Town NEW yugi< 3.d. State 3.e. ZIP Code N I D2 78 3.f. Province 3.g. Postal Code 3.h. Country 2a FED6_12AL PLA2A FIr. 0 Li N ran smerec Pireparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. g I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent. 7.b. O I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends 0 does not extend O beyond the preparation of this form. Voreparesnefroreson, By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of at the request of, and-with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when required, supplied additional information to respond to a question on the form. 8.a. 8.b. NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper, type or print your name and 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 date and sign each sheet. Form 1-102 10/19/17 N Page 4 of 4 EFTA01699766 APPlinptitot For. EMployment Authorization Pepartineat-Of SOmetanctSecurity U.$: Citizenship andimmigratibn Services. TiRaS . Form T-7.65 OMB Ho. 1615.0040 Expires 05/31/2020 El Authorization/Extension ValidTrom . . teeStinlit Adtion block `For WSCISI Vat I 0 Authorization/EXtention Valid:Through 0 1'4 i Alien Registration Number A- I • .. . . I i z s . Remarks • To be completed byamattorne tor Board of Immigration acereditgdItte,p.Mseittneninif anY% Seidelbeittsi,a(onitt; s2g latittatbedi .-•. Atteen4Yer Accredited Rel eotative 1.1.S4S500#e-AcCOOlt-NI.#01,r (if any) 1. r 1 •• ► STARTElin - TtMe Orpri Riblitekink Tart 1.. Reason for Applying I am apnlyitiglor (selettotiVonamt): La. El. Initial•permIssionm accept employment Lb, El Replacententollbstrstolen,nr dinnagedsmpkVineht authOrizatioitclootirnent,-Ortorreptiottof tiiy emplOyinentauthoriXatibwittictarieht•NOT:DOE to U.S, OitizenShipandlintnigratiotiSertdcet(OSCIS) error. NOTE: Replacement(correoti0:0 eat employment mithoristiOwdeconieftdue.tbAJSCIS err& &allot require a new IlbrarT,76$ ant tili4fe6. Refer-to RSplactinentlor CarannettrlinNiibirtsisthe Filing7Fee section oltheEcirm 146SinipitOtiona for further 1.e. K Renewof-mypermissiorto acceptemployinent (Actiteirazt0pyptyouppreviotis.entployineitt authoriaatioadocemeet.) .nfOtioilanaStilott$ TON La. Family Name (Lett Name) Lb. Given Name (Pint Name) Le. NfiddleName. IfteriThat proVitle.all-etheragmles:yoh have ever used, including aliases, maiden name,. antInt6kintities. Ora neett ram space to tomplookshis section,, usothespace provided in Part 6. AddItional•Ihforma Name :(LitstNant6). Given:Name . (4litst Igaine) Xs. Middle Name. . . Xt. Fartilly:Naine (Last Maine) lb. eineName .(Firstblime) .MickileNlipe 4.a. 4:0. Tamil Naipt: (1st Name) Given:Ndme • (Firselslame). • 4.e. Middle Name Form I-765 Ot26/19 FUltalIMMEMEMPROMIIIII Page 1 Ml EFTA01699767 frt tf 2. ThroMnii0t1, Ybrt$OttnUfftilll I 5.a. In Care Of Warne (if any) 5.b. Street Number and Name 5.c. 12 Apt 0 Ste. 0 Flr. 5.d. City or Town 5.e. State Ny ZIP Code 6. Is your current mailing addiesSliteaem asickUrplinical address? ?gliYes ONO NOTE: If94u. anaWererNO" totem-041111litre., provideyourphySietliaddress-belom - , trt. Street Numbs* andName 'Lb. In- Apt. LI'Ste. 15.. 134b. Provide your Sodiel.Secuti num N. Do you want-the SSA. to issueyon a Social:S.ecurity. card? (You4bnatelap answer "Yes" tolteanNtimber 15., Consent for -DiselPsurt, to reteiVe.a. card.) 0 Yes No NOTE; If you answered "No" tmItetn.hintober 14., skip to.Fart7.., Item •b.lumbet18.a. Ifyou answered "Yes" to ItemNumber 14., you mussaiso answer "Yes" to Item Nttifiber 15. consent.forDiscloattre; LeuthorizecjiseloSure of infortiunioniftpintills:itifplicatibn tot/m.55A as required for the purpose ofOsigriingintanS5Istand itsuing Me a SocialSeentitY Gerd 0Yes QNo NOTE: If you answered "Yet" to Hera Numbers N. - 1$,,,providelhe information requested'tn Item Nutiffitta.164, -173), lather's.Nable Provide your fathere birlltnikne. 16.a. Tamilybianie (LasiName) 1633. Given Name (FirstNatne) 7.c. City or 7.d. State Town MpthersName Provide:your mother's 117.a. nuttily Name (Last Mole) birth name. • 74. tffitodel areiret Interning f for 04h Given Name (First:Name) S. Alien Registration Nutriber(A-Num060(itiknyi . * A- - ; .1 ire& fp aunte MOO IrciiirepishOvr• 9. USCP.OnlineckeepulitNuMber(if.any). ptCyllOnglity alleOuntries wherey0trareturrentlyn citizen or national. P. I -I. I : ; I . Ifyottoeedtektevapacoto. complete this. item, use ibe space 10. Gender -(81 Female .pfitividoliivrairtk Mdikionallinform.ation. 11. MaritarStatus ('Single 0 Married. ;'Divorced 0WidOwed 10. Have you previbealy Sled ForitrI-765? 1133): _try °Yes ON° 13.a. Has theSociatSecurity Administration(SSA):ever officially issued a Social Security card to you? g Yes 0N° NOTE: If you.ansWered "No" Whim Number 13.a., skip to Rein Number 14. If you answered "Yes" to Item Number 13.24 provide thetfoimatiortrequeSteditiban Number13.1). Form 1-765 12126/19 Page 2 of 7 EFTA01699768 'Pant kfOrMatiott About VOu (tentanUed)/ List the city/town/village, state/province, and country where you were born. 27. Eligibility Category. Reflect° the Who 1465 section of-the:Form-I-765 Instructions the appropriate eligibility-category for Enter theiMproptiate letterand.nainber category:5Mb* (for-example, (a)(8), (WI this for May File -Form to determine application. your eligibility (iii)). • 28. (e)(3)(C)STEM'OPT Eligibility Category: If you 19.b. State/Province of Binh entered the.oligibility category(e)(3)(C) in Item Number 27., provideithe information requestedinitemNtitithers 28.a 28m. njermation About YourEligibilittedtegory 19.0 Cou ofBirth 20. Date ofairthOun/eldfioyy) Aforn7alion:4tout Your Last Arditallathr UstitedStapif ;1.a. Form I-94.Arrival bepatinreatoordNumber (itany), 2ub, Most RcoentlyzIsstred•Paasport 21.e. Travel Document Number (if any): 214. . • ixtE0yr.PasSpOrtorltaveliDocurnent 21.e. Expiration-bate for Passport Or (iftre/ddlyyyy) 22. DateolYotglastArtivallito.the-UnitedtnItes Ortor Abour(finti/dd/yra) 23. Place of tour Last Arrival Inter the.Unitt&States cos. 644.;leterS 24. Immigration Status at Your Last Arrival. (for-example, 8-2Viaiter,1L1 student, or no status) a 25. YourCument Immigration-Status or Category4for. =ornate, B-2 visitor, F4 student, parolee, deferred.action, or no status or category) 26. Studentriad Exchange Visitor Information System (SEVIS)Number (if any) - 284.13egret 28ito. Bmploycesfitrim as Lisy4iwacyaify 28.e. Employer's E-VeriftCbmpany Identification Nmilbet or a Valid E-Verity CliesinCOmpanyidentification Number .(eX26),Efigibilitytategory. If yon.entered-the eligibility category (426) in Itear-Ntnnber 2.t.,•pinvide the receipt number:ofyour 11-1ftspouse's most recent Petal I-797 Notiarfor FOtin I-129,Petition fora Nonimmigrant Worker. I 1 30. (e)(8)EligibilitrCategary. If yotraitered the.eligibility category (oX8) inf tem Number 27., have you EVER been arrested for and/or convicted of any crime? OTh K No NOTE: If you answered "Yes" to Item-Number 30., refer to Spadini Tiling InstructiOntfor Thote With Fending:Asylum Applieationsfe)(8)inthe Required Becumentation section of the Form I-765 .instructions for.information abontproviding court dispositions. 31.a. (c)(35)and.(c)(36) Eligibility-Category. Ifyou entered critegoir(o)(35)1n•BentrNuMber 27.,.please provide•thc receipt:number of your Fortn I-797 Notice for Form 1440, Immigrant Petition for Alien Worker. If you enteredthe eligibility category (c)(36)in Item Number 2/.,.please provide the receipt number-of your spouse's or parent's Form 1-797iNglitefOr FOnn1440, ► 31.b. If you entered the eligibility category (eX33) or (o)(36) in Item Nuntber27., have yowEVER been arrested for and/or convicted of any crime? UYes EiNo NOTE: If you answered "Yes" to Item Number 31.b., refer to Employment-Based Nonimmigrant Categories, Items I. - 9., in-theWho-May File Form I-765.section of the Fonn.I-76S Ihstmctions forinfomtatiowabout providing court dispositions. Form I-765 12/26/19 Page 3 of? EFTA01699769 art 3. Applicant's Statement, Contact !Information, Declaration, Certificationvand! Signature NOTE: Readthetenaltiessection.d.the Forin 1-766 Instructions before compledirgibi.s section. You mustae Form I-765 while in the United States. Appikanealatement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. 1Z1 I can read and understand Engliak andthave read And UnderstaricTeVery questionandinttibctiorfomthis application and my.answerte-every rmestion. Lb. ThoihterpreternaihedinFart.4..readtene question and instruction on this applicationkiidMy tiMvyerM every question in language in which Tam flaent, andI untletstriod everything. 2. A5 request; the prepaterzneumciligartr6.„,, preparedthis application for tnegamed'Ohly. upon inforniaticin I provided& authorited. AppliontWtontad infoitmatiOn, 1 3. Applibruirs Daytime Telephone Numb 4. Applicant Mobile telephorieVziniberfipal; 5. ApplipanestmailMirot(itany) - 6. El Select-thistoxif you area Salvadozan.or qualemaltut national' eligible for Benefits under the. Ape settlement agreement. Applicimt freelOratibitatifettliftattoit Copies of any documents•I have submitted are exact photocopies of unaltered, originaIdocuments,:andlunderstand that USCIS May retttriro that I subrnitorigirialdocuments to USCIS at a later date. Furthermore,.I authorize therelease of any inforthation tabula* mid all.of my records thatUSCIS.may neetto detain:line my eligikility for the finmigration.beneflithat I seek. Ifurther:mare authorize release ofinfonnation contained in this application, in supporting documents, and in my USCIS records, to other entities and.persons where necessary for the adminittration and enfottementof U.S. immigrationiew. I understand that USCL5may require.me to appear for an appoint:tier:No take My'biomelties (fingerprints, photOgraph, zurdloreignature) and, at that time, if I am reel:fired to provide bioreetrice, rittridied tO.aign an oath reaffirming that ItevieWtdandunderstoodzall•0f thejnformation contained in„and subthitted with, my appliCatiOn; and 2). 411-ofthis.inforrnation was complete, true,.and correct at the time offiling. liderlify, undet penalty. of.perjury, that all of the information in My applitation and any dbeurn:Matairlmilitted•withit were provided of autholizedbymie, that reviewedand uliderataftel all.of the informati.5a4mitained in, and aubmitted With, my .application andthet alLof this infdrmation•is complete, true, and correct 7.b. Date of Signature (dtnidtVyys7) 03414 (tow NUTS Aix AOLICANTS: If you do.not completely fill out.this:application or fiato submit requitadocuments listed in the Insituctions,USCIS rhay•climy your application. lOart 4. IntetpreterteOntactinfOrinafttv .'Certification,andSigpature, • - Provide the-following information OM the interpreter. :fifiteVatkil, Frenfkinet la. Interpreter's, Family Name (Last Name) 1.b. Interpreter's GivenNamt(First Name) 2. Interpreteds Business or Organization Name Of any) Form 1-765 12126/19 III integri4zuparmite rake 1 m Page 4 of 7 EFTA01699770 Part 4. Interpreter's Contact In formatict4 fertificatiOnrand Signature 3.a. Street Number and Name 3.b. El Apt 0 Ste. K Fir. 3.c. City or Town 3.d. State 3.f. Proving!' 3.g. Postal COS j 3.h. Country 3.e. ZIP Code aftpreteaseantaelintimmalk* 4. literprptadspaytitno.lbIlliont Nigh* r : 7'1 . 3.11, El Apt. a Ste. larlik !Part 5. Contact Inconunntion, Declaratialhad iSignat urelatthaPtitantitneparing this. Applicatinny Iffqater Tnaza the Applicant provide Oietellowiatinfoltualongoutine preparer. tweparertstfiterNamg, . . La. ilyNante (Laid Nana) e (firstName) 2. Vtepatee.;$usinet.s:ot,QTganitation Nnte:(if any). etira faMfgiling AftrY4 3a. and atftneam. ickiktPc N • • s ."‘14. 5. Interpretetl.biollile Telephone Mannegi so) 6. Interpretedsmaii Addresrgapy), Otterpreteestroaallort I certify, uncler pentdty:of perjury, that • Lam-fluentda which is the.stheiniguagestiecificabibtiiitt3., iternaraii2bei LfrandthaVe readto thit.appliCantin•theiidentitledlangbage every.cfuestiptrafteisti-uotierteit.this.applicatiee rindiii,corher answer to every question. Thcopplitpt ialinedmedaithe of she understanda every instruction, qt!.4tieilyenel,answei on-the application, inchMingthe Applicants VecliitAtionlind Oettifitation, and .has vetifietttheaccuntey °Eton lumen ninir;ter‘iiiitabir 1 7.a. Interpreter's $!gitattny 733. Date of Signature (mmiddiyyyy) City.or town • Id. State 34. Ptoyince 3+ Postal Code Csingtex lee Cade. 10.276 N1' C5rikr-es 044pgreKwdotNomoWit 4. 5. 6, Pr aterfstpayOrhe Telephone Number . Preparees.Mobile Telepbene.Number (if any) • • • .fisP.meil.Address(iciarty). Form I.765 12/26/19 Page 5 of 7 EFTA01699771 Part 5. Contact tniontnatiOn, beclaration, and' Signature citthe P,erson Preparing this Application, it Other Than the Applicant ,(continued 7.a. a lam not an attorney.or accredited representative but have prepared-this application on behalf of the applicant and with the applicant's Consent. 7.b. oI am an attorney or accredited representative and my represehtati0n &the applicantrin thireale El❑extends bdoct noteidendttypit4lbct. preparation of thisapplicaliOn. NOTEF Ityotriettiztiltorit*yOtAcctetlited rdpittentativet ply,thay: needle subillt a cornpletedTont.04kbrotico.oftritay of AppearancesitrAttonaepds k.constlitett Representative, withrthisapplidatitut. IPtejkotift ea/Pal/oft Efy my signature, !certify; under penalty of perjury; thatl prepared this Opilicatibrpatthe request of the applicants The applicanttlien itviessiediffittornpittotapnlication.anct informedMothatbe.or She understanda all of theinfonhation. contained in, anrksulanitte&With„hia.ok heiapplication, including the Applicant's DrAiriitiOn IittLeertification, and that allof this infoimationis coifipItte, true, and.coftct. completed'thiSapplicatiowbased only owinfennatioWthasthe applibtutt prosidetholneorauthosizettmetwObtaiworust Oieepitterct,Pknalure kb. Date of Signature (nt yyyy) Formai-765 12/26/19 IIII faliiMICRWMPAWEIMMIIIII Page 6 of 7 EFTA01699772 Part4. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you. heed'inote space than what is provided, yob may inake.copie4 of this page to complete and fde with this application. Or.attach &separate. sheet of paper. Type or print your name and Asblumber(if any.) at the top of each sheet; indicate the PageNuniber, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Family Name (Last Neale) 1.b. Given Name (First Naine) 1.c. Middle Name 2. A-Number (itanA. * A 1 i - I . 31a. PageNunther 3,1f. 1WtNtintber 3i,e, I 34. 4.d. Page-Number 4.b, Part blumber 4A Item:Number 5.a. Page Number 5.b. IPartNumber, Le. Item Number I. 6.a. 11.'40:Number 64 Part lumfler 6.c. Item Number 74. Form I-765 12/26/19 RONIMEMOIStiftifttliSMUMIIIII Page 7 of 7 EFTA01699773 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. 'Fel: I -800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CBS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is pros ided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Race: Date of Birth: NYFBINYC 0 Female Unknown NO NCIC WANT RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Federal NCIC WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CRS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Race: Date of Birth: Female Unknown EFTA01699774 NYFBINY 0 0 NO NCIC PROTECTION ORDER FILE RECORD RAC/U SEX/F Additional Inquiry Response ORI: NYRBINV00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel- Michael C.Grccn, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *III Information * The following information is provided in response to your request fora search of the III based on: Name: Sex: Race: Date of Birth: Female Unknown Purpose Code: NYFBINY00 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM DOB/ .SEX/F.RAC/U.PUR/C.ATN/MEDERR. END EFTA01699775 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJ IS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Race: Date of Birth: NYFBINY00 Female Unknown NO NCIC WANT NAM/ DOB RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel. Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJ IS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC EFTA01699776 restricted and nonrestricted The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Race: Date of Birth: NYFB INY 0 D Female Unknown NO NCIC PROTECTION ORDER FILE RECORD NAM/ DOB/ RAC/U SEX/F Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St Albany, New York 12210. Tel Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services ti III Information * The following information is provided in response to your request for a search of the III based on: Name: Sex: Race: Date of Birth: Female Unknown Purpose Code: NYFRTNY00 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM/I END DOB/ .SEX/F.RAC/U.PUR/C.ATN/MEDERK. EFTA01699777 DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE Part A: Information on the Victim 1. Name: (Last) 2. Date of Birth (mo., day, yr.) 5. Alias(es) 8. Passport Number 11. Social Security Number (First) 3. Country of Birth (Middle) 4. Country of Citizenship 6. Gender (check one) 7. Alien Number (A#) K Male K Female A 9. Country of Issuance 10. Expiration Date (mo., day, yr.) Part B: Requesting Agency Information •Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: 2. Daytime telephone number 3. Fax number (First, Last) (include area code) Ext 2. Case Agent where the Victim resides (if the Victim resides in a jurisdiction other than that of the Lead Case Agent): (First, Last) Supplemental Information: Requesting Agency: 2. Daytime telephone number 3. Fax number (include area code) Ext. Group Supervisors Daytime telephone number (including area code) Fax number ext. name (First, Last) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA01699778 Victim-Witness Specialist's/Coordinator's name (First, Last) Daytime telephone number (including area code) Fax number ext. Part C: Case Information Wote: Please complete all information below. 1. Is the Victim currently in the United 0 Yes 0 No States? 2. The Victim's current immigration status: 3. Is the Victim requesting Continued Presence based upon a pending civil action under 18 U.S.C. § 1595? CI Yes 0 No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? 0 Yes glio (if yes, where and when) City, State: 5. When did the Victim enter the United States? 6. Through which Port of Entry did the Victim enter the United States? 7. How did the Victim enter the United States? n r Part D: Specific Information Pertaining to the Victim * Please answer each question as completely as possible (Attach additional sheet(s), if necessary.) 1. Significance and value of the Victim to this case: (Please provide a brief explanation of how the Victim meets the definition of "severe form of trafficking' under section 103(8), Victims of Trafficking and Violence Protection Act of 2000, Pub. L. No. 106-386.) 2. The Victim's criminal Involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) 3. Risk the Victim presents to public safety and/or to national security (i.e., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary; (Attach copy of risk assessment report) 4. Financial responsibility for the Victim: (Please explain manner in which the Victim's living expenses will be met) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA01699779 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state; attach additional sheet(s), if necessary.) 6. Is employment authorization requested? K Yes K No (If yes, please attach completed U.S. Citizenship and Immigration Services Forms 1-765, Application for Employment Authorization, and 1-102, Application for Replacement/Initial Nonimmigrant Arrival/Departure Document.) Note: Information contained in question # 7 is not required for a victim to receive Continued Presence; however, this information is required for a victim to be certified to receive benefits from the Department of Health and Human Services (HHS), Office of Refugee Resettlement (ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. Is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. ✓Yes K No Part E: Location where the Victim will reside (City and state are required at a minimum.) Street Address City State *Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for Continued Presence must be submitted to the ICE HSI Headquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reported to the requesting agency headquarters, which in turn will notify LEPU. The requesting agency will also notify LEPU immediately if the alien departs the United States. Part F: Certification of Reporting Requirements As the requesting agency representative, I understand that, should this Continued Presence be granted, it is MY responsibility to follow all of the policies and procedures established by LEPU, including quarterly reporting, reporting changes in the Victim's status (i.e., departure or change in status), and requesting applicable extensions 30 days prior to the expiration of approved Continued Presence. (Lead Group Supervisor's Signature) (Print Name and Title) (Lead Case Agent's Signature) (Print Name and Title) (Date) (Date) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) f3age 3 of 4 EFTA01699780 If the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Tide) (Monitoring Case Agent's Signature) (Print Name and Title) Privacy Act Statement (Date) Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form will be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting law enforcement officer/agent and their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, intemational or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted under 5 U.S.C. § 552a(b) pursuant to the routine uses published in the Department of Homeland Security system of records notice, DHS/ICE-011 Immigration and Enforcement Operational Records. Disclosure: The disclosure of the information on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of the request for Continued Presence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 4 of 4 EFTA01699781 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-102 OMB No. 1615-0079 Expires 10/31/2019 For USCIS Use Only Receipt Action Block New 1-94 Number Remarks 0.• START HERE. Type or print in black ink Part 1. Information About You 1. Alien Registration Number (A-Number) la• A- 2. USCIS Online Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name MPH U.S. Mailing Address 4.a. In Care Of Name 4.b. Street Number and Name 4.c. Apt p Ste. 4.d. City or Town 4.e. State Weil m gory. 4.f. ZIP Code 100(.95 5. Is your current U.S. mailing address the same as your U.S. physical address? ErYes 0 No If you answered No" to Rem Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.f. U.S. Physical Address 6.a. In Care Of Name To Be Completed by an Attorney or Accredited Representative, if any. O Select this box if Form O-28 is attached to represent the applicant Attorney State License Number 6.b. Street Number and Name 6.c. Apt. O Ste. 6.d. City or Town 6.e. State O Flr. O 6.1. ZIP Code Other Information 7. Date of Birth (nmildcliyyyy) 10. 8. un of Birth 9. Coun of Citizenshi 10. U.S. Social Security Number if an Entry Information 11. Date of Last Entry into the United States (mni/dellyyyy) ► oi/a/e301° 12. Place of Last Entry into the United States (City and State) Los Ankles ) CA Form 1-102 10/19/17 N Page 1 of 4 EFTA01699782 Part 1. Information About You (continued) 13. Current Nonimmigrant Status Visa 14. Date Status Expires (mnt/dd/yyyy)10. oa/ast i 15.a. Form I-94,1-94W, or I-95 Arrival-Departure Record Number 15.b. Passport Number 15.e. Travel Document Number 15.d. Coun of Issuance for Passport or Travel Document J 15.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) ► 08* q boo Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) 1.a. O I am applying to replace my lost or stolen Form 1-94 or I-94W. 1.b. ID I am applying to replace my lost or stolen Form 1-95. 1.c. O I am applying to replace my Form 1-94 or I-94W because it was mutilated. I have attached my original Form 1-94 or I-94W. 1.d. O I am applying to replace my Form I-95 because it was mutilated. I have attached my original Form 1-95. 1.e. [Punts not issued Form I-94 when I was admitted by CBP at a port-of-entry in the United States (whether at a land border, airport, or seaport). 1.f. K I was issued Form I-94, I-94W, or I-95 with incorrect information, and I am requesting that USCIS correct the document I have attached my original Form 1-94, I-94W, or 1-95. 1.g. O I was not issued Form 1-94 when I entered as a nonimmigrant member of the military, and I am filing this application for an initial Form 1-94. tevne,Weol Passport Part 3. Processing Information 1.a. 1.b. Are you filing this application with any other petition or application? O Yes No If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number 1.b. USCIS Form Number and Name 2.a. Are you now in removal proceedings? O Yes 'No If "Yes" complete Item Number 2.b. 2.b. Provide detailed information regarding the proceedings. If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. If you are unable to provide the original of your Form 1-94, I-94W, or 1-95, provide the following information: NOTE: Provide your name exactly as it appears on Form 1-94, I-94W, or I-95. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Class of Admission at Last Entry into the United States 5. Place of Last Entry into the United States (City and State) Lees -Amities 1 OA Form 1-102 10/19/17 N Page 2 of 4 EFTA01699783 Part 5. Contact Information, Certification, and Signature of the Interpreter (continued) Interpreter Certification I certify that: I am fluent in English and is the same language provided in Part 4., Item Number Lb.; I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number 1.13.; and The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question. 6.a. Interpreter's Signature ,which 6.b. Date of Signature (rimildd/yyyy) ► Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparers Family Name (Last Name) Lb. Prepares Given Name (First Name) 2. Prepares Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. K Ste. K Flr. K 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number S. Preparer's Fax Number 6. Preparers E-mail Address 7.a. K I ant not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent. 7.b. K I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends K does not extend K beyond the preparation of this form. Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when required, supplied additional information to respond to a question on the form. 8.a. Prepares Signature 8.b. Date of Signature (rmn./dd/yyyy) ► NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper, type or print your name and 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 date and sign each sheet. Form 1-102 10/19/17 N Page 4 of 4 EFTA01699784 Part 4. Statement, Certification, Signature, and Contact Information of the Applicant NOTE: Select the box for either Item Number l.a. or Lb. If applicable, select the box for Item Number 2. l.a. K I can read and understand English, and have read and understand every question and instruction on this form, as well as my answer to every question. 1.b. O The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above. 2. K I have requested the services of and consented to who is K is not K an attorney or accredited representative, preparing this form for me. Applicant Certification I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws. 3.a. Applicant's Signature S 3.b. Date of Signature (mm/dd/yyyy) ► Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: l.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 1 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Sheet Number and Name 3.b. Apt. K Ste. K Fir. K 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address Form I-102 10/19/t7 N Page 3 of EFTA01699785 Application For Employment Authorization Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-765 OMB No. 1615.0040 Expires 05/31/2020 Authorization/Extension Fee Stamp Action Block Valid From For Authorization/Extension Valid Through USCIS Use Only Alien Registration Number A- I I I Remarks To be completed by an attorney or Board of Immigration Appeals (13IA)- accredited representative (if any). Select this box if Form G-28 is attached. Attorney or Accredited Representative USCIS Online Account Number (if any) ► START HERE - Type or print in black ink Part 1. Reason for Applying I am applying for (select only one box): l.a. O Initial permission to accept employment. I.b. D Replacement of lost, stolen, or damaged employment authorization document, or correction of my employment authorization document NOT DUE to U.S. Citizenship and Immigration Services (USCIS) error. 1.c. NOTE: Replacement (correction) of an employment authorization document due to USCIS error does not require a new Form 1-765 and filing fee. Refer to Replacement for Card Error in the What is the Filing Fee section of the Form 1-765 Instructions for further details. Renewal of my permission to accept employment. (Attach a copy of your previous employment authorization document.) Part 2. Information About You Your Full Legal Name I.e. Family Name (Last Name) I.b. Given Name (First Name) 1.c. Middle Name Other Names Used Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 6. Additional Informer 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Form 1-765 12/26/19 'III Page 1 of 7 EFTA01699786 Part 2. Information About You (continued) Your U.S. Mailing Address 5.a. 5.b. Street Number and Name 5.e. Apt. K Ste. K Flr. 5.d. City or Town 5.e. State Naze) uor- 5.f. ZIP Code I 00105 6. Is your current mailing address the same as your physical address? []'Yes 0 No NOTE: If you answered "No" to Item Number 6., provide your physical address below. U.S. Physical Address 7.a. Street Number and Name 7.b. K Apt. K Ste. K Flr. 7.c. City or Town 7.d. State Other 17.a. Family Name (Last Name) 17.b. Given Name (First Name) Information 8. Alien Registration Number (A-Number) (if any) ► A- Your Country or Countries of Citizenship or 9. USCIS Online Account Number (if any) Nationality List all countries where you are currently a citizen or national. 10. Gender K Male [✓Female If you need extra space to complete this item, use the space provided in Part 6. Additional Information. 11. Marital Status 18.a. Coun Eraingle K Married K Divorced K Widowed 12. Have you previously filed Form I-765? 18.b. Country ❑Yes E'No 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ErYes K No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you answered "Yes" to Item Number 13.a., provide the information requested in Item Number 13.b. 7.e. ZIP Code 13.b. Provide your Social Secu PO' 14. Do you want the SSA to issue you a Social Security card? (You must also answer "Yes" to Item Number 15., Consent for Disclosure, to receive a card.) 0 Yes 0 No NOTE: If you answered "No" to Item Number 14., skip to Part 2., Item Number 18.a. If you answered "Yes" to Item Number 14., you must also answer "Yes" to Item Number 15. 15. Consent for Disclosure: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security card. K Yes K No NOTE: If you answered "Yes" to Item Numbers 14. - 15., provide the information requested in Item Numbers 16.a. - 17.b. Father's Name Provide your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mother's birth name. Form 1-765 12/26/19 ItIMPINSPONEWS=MallIIII Page 2 of 7 EFTA01699787 IPart 2. Information About You (continued) Place of Birth List the city/town/village, state/province, and country where you were born. 19.a. CityfrownNillage of Birth 19.b. State/Province of Birth 19.c. Country of Birth 20. Date of Birth (mm/dcVyyyy) Information About Your Last Arrival in the United States 21.a. 21.b. 21.e. 21.d. Form I-94 Arrival Ito Passport Number Departure Record Number (if any) 29. 30. (c)(26) Eligibility category (cX26) number of Notice for Worker. ► (c)(8) Eligibility category (c)(8)in been arrested Category. If you entered the eligibility in Item Number 27., provide the receipt your H-1B spouse's most recent Form 1-797 Form 1-129, Petition for a Nonimmigrant of Your Most Recently Issued Passport Travel Document Number (if any) Category. If you entered the eligibility Item Number 27., have you EVER for and/or convicted of any crime? Country That Issued Your Passport or Travel Document Information About Your Eligibility Category 27. Eligibility Category. Refer to the Who May File Form I-765 section of the Form I-765 Instructions to determine the appropriate eligibility category for this application. Enter the appropriate letter and number for your eligibility category below (for example, (aX8), (cX17)(iii)). (Mu 28. (c)(3)(C) STEM OPT Eligibility Category. If you entered the eligibility category (cX3XC) in Item Number 27., provide the information requested in Item Numbers 28.a - 28.c. 28.a. Degree 28.b. Employer's Name as Listed in E-Verify 28.c. Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number 21.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 22. Date of Your Last Arrival Into the United States, On or About (mm/dd/yyyy) 23. Place of Your Last Arrival Into the United States 24. Immigration Status at Your Last Arrival (for example, B-2 visitor, F-I student, or no status) 1 25. Your Current Immigration Status or Category (for example, B-2 visitor, F-I student, parolee, deferred action, or no status or category) 26. Student and Exchange Visitor Information System (SEWS) Number (if any) ► N- El Yes ONo NOTE: If you answered "Yes" to Item Number 30., refer to Special Filing Instructions for Those With Pending Asylum Applications (cX8) in the Required Documentation section of the Form I-765 Instructions for information about providing court dispositions. 31.a. (O(35) and (cX36) Eligibility Category. If you entered the eligibility category (c)(35) in Item Number 27., please provide the receipt number of your Form 1-797 Notice for Form I-140, Immigrant Petition for Alien Worker. If you entered the eligibility category (eX36) in Item Number 27., please provide the receipt number of your spouse's or parent's Form I-797 Notice for Form 1-140. 31.b. If you entered the eligibility category (cX35) or (cX36) in Item Number 27., have you EVER been arrested for and/or convicted of any crime? ❑Yes K No NOTE: If you answered "Yes" to Item Number 31.b., refer to Employment-Based Nonimmigrant Categories, Items 8. - 9., in the Who May File Form I-765 section of the Form I-765 Instructions for information about providing court dispositions. Form I-765 12/26/19 VgartIPSIsitigNittrttliginling011111 Page 3 of 7 EFTA01699788 Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-765 nstructions before completing this section. You must file Form I-765 while in the United States. Applicant's Statement NOTE: Select the box for either Item Number l.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. Olean read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. El The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in a language in which I am fluent, and I understood everything. 2. El At my request, the preparer named in Part 5., prepared this application for me based only upon information I provided or authorized. Applicant's Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant's Contact Information Applicant's Signature 3. Applicant's Daytime Telephone Number 7.a. Applicant's Signature 4 4. Applicant's Mobile Telephone Number (if any) 7.b. Date of Signature (nunAld/yyyy) 5. NOTE TO ALL APPLICANTS: if you do out this application or fail to submit required in the Instructions, USCIS may deny your application. not completely fill documents listed Applicant's Email Address (if any) 6. El Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC settlement agreement. Part 4. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name l.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Form 1.765 12/26/19 Ill Walgialealrefiktffittailfeiallfill Page 4 of 7 EFTA01699789 Part 4. Interpreter's Contact Information, Certification, and Signature Interpreter's Mailing Address 3.a. Street and Name 3.b. K Apt. 3.c. City or 3.d. State 3.f. Province 3.g. Postal 3.h. Country Number K Ste. Town Preparer's 1.a. 1.b. 2. Preparer's Full Name Preparer's Family Name (Last Name) K Flr. Preparer's Given Name (First Name) 3.e. ZIP Code Code Preparer's Business or Organization Name (if any) Mailing Address Interpreter's 3.a. 3.b. Street Number and Name K Apt. K Ste. Contact Information K Flr. 4. Interpreter's Daytime Telephone Number 3.c. City or Town 5. 3.d. State 3.e. Interpreter's Mobile Telephone Number (if any) ZIP Code 3.f. Province 6. Interpreter's Email Address (if any) 3.g. Postal Code 3.h. Country Interpreter's Certification I certify, under penalty of perjury, that: Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information about the preparer. I am fluent in English and which is the same language specified in Part 3., Item Number 4. Preparer's Daytime Telephone Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Interpreter's Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mmiddiyyyy) Preparer's Contact Information 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Form 1-765 12/26/19 Cpl IMERIAMPaiffnicallPI Page 5 of 7 EFTA01699790 Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant (continued) Preparer's Statement 7.a. K I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent 7.b. El I am an attorney or accredited representative and my representation of the applicant in this case 0 extends El does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8.a. Preparer's Signature 8.b. Date of Signature (mmidd/yyyy) Form 1-765 12/26/19 11111 FUMMIPPOStitt6IMINDTATIMIIIIII Page 6 of 7 EFTA01699791 Part 6. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and 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. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) l.c. Middle Name 2. A-Number or any) lo A- 3.2. Pa e Number 3.b. Part Number 3.d. 3.c. Item Number 4.a. Pa Number 4.b. Part Number 4.c. Item Number 4.d. 5.a. Pa e Number 5.b. Part Number 5.c. Item Number 5.d. 6.a. Pa e Number 6.b. Part Number 6.e. Item Number 6.d. 7.a. Pa e Number 7.b. Part Number 7.c. Item Number s_ 7 7.d. Forrn 1-765 12/26/19 El morommargentwommt Page 7 of 7 EFTA01699792 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-102 OMB No. 1615-0079 Expires 10/31/2017 For USCIS Use Only Receipt Action Block New 1-94 Number Remarks ► START HERE. Type or print in black ink Part 1. Information About You U.S. Physical Address To Be Completed by an Attorney or Accredited Representative, if any. K Select this box if Form G-28 is attached to represent the applicant Attorney State License Number 1. Alien Registration 2. USCIS Online Number ► A- Account Number (A-Number) 6.a. 6.b. 6.c. In Care Of Name I I I (if any) Street Number and Name Apt K Ste. I I I i K FIr. K Your Full Name 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6.f. ZIP Code 3.b. Given Name (First Name) Other Information 3.c. Middle Name U.S. Mailing Address 7. 8. Date of Birth (mm/dd/yyyy) ► Country of Birth 4.a. In Care Of Name 9. Country of Citizenship 4.b. Street Number and Name 4.c. Apt. K Ste. K FIr. K 10. U.S. Social Security Number (if any) 4.d. City or Town Entry Information 4.e. State 4.f. ZIP Code 11. Date of Last Entry into the United States 5. Is your current U.S. mailing address the same as your (mmirld/3557) ► U.S. physical address? K Yes fl No If you answered "No" to Item Number 5., provide your 12. U.S. physical address in Item Numbers 6.a. - 6.f. Place of Last Entry into the United States (City and State) Portal-102 12/23/16 N Page I of 4 EFTA01699793 Part 1. Information About You (continued) 13. Current Nonimmigrant Status 14. Date Status Expires (11mAid/Y)731) ► liart 3. Processing Information 1.a. Are you filing this application with any other petition or application? 0 Yes 0 No If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number 1.b. 15.a. Form I-94,1-94W, or I-95 Arrival-Departure Record Number USCIS Form Number and Name I I 15.b. Passport Number /a. Are you now in removal proceedings? 0 Yes 0 No If Wes" complete Item Number 2.b. 15.e. Travel Document Number 2.b. Provide detailed information regarding the proceedings. 15.d. County of Issuance for Passport or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; 15.e. Expiration Date for Passport or Travel Document indicate the Page Number, Part Number, and Item (mm/dd/yyyy) ► Number to which your answer refers; and date and sign each sheet. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) 1.a. 0 I am applying to replace my lost or stolen Form I-94 or I-94W. 1.b. O I am applying to replace my lost or stolen Form I-95. 1.e. O I am applying to replace my Form I-94 or I-94W because it was mutilated. I have attached my original Form I-94 or I-94W. 14. El I am applying to replace my Form I-95 because it was If you are unable to provide the original of your Form I-94, mutilated. I have attached my original Form I-95. I-94W, or I-95, provide the following information: 1.e. O I was not issued Form I-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form 1-94, CBP at a port-of-entry in the United States (whether at a land border, airport, or seaport). I-94W, or I-95. 3.a. Family Name IS. 0 I was issued Form I-94,1-94W, or I-95 with incorrect (Last Name) information, and I am requesting that USCIS correct the document. I have attached my original Form I-94, I-94W, or I-95. 3.b. Given Name (First Name) 3.c. Middle Name 1.g. O I was not issued Form I.94 when I entered as a nonimmigrant member of the military, and I am filing this application for an initial Form I-94. 4. Class of Admission at Last Entry into the United States 5. Place of Last Entry into the United States (City and State) Form I-102 12/23/16 N Page 2 of 4 EFTA01699794 Part 4. Statement, Certification, Signature, and Contact Information of the Applicant NOTE: Select the box for either Item Number 1.a. or Lb. If applicable, select the box for Item Number 2. La. O I can read and understand English, and have read and understand every question and instruction on this form, as well as my answer to every question. 1.b. O The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above. 2. O I have requested the services of and consented to who is 0 is not 0 an attorney or accredited representative, preparing this form for me. Applicant Certification I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws. 3.a. Applicant's Signature 4 3.b. Date of Signature (mmicld/yyyy) ► Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: I.a. Interpreter's Family Name (Last Name) Lb. Interpreters Given Name (First Name) 2. Interpreters Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. O Ste. 0 FIr. 3.c. City or Town 3.d. State 3.f. Province 3.g. Postal Code 3.h. Country 3.e. ZIP Code Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address Form 1-102 12123/16 N Page 3 of 4 EFTA01699795 Part 5. Contact Information, Certification, and Signature of the Interpreter (continued) Interpreter Certification I certify that: I am fluent in English and is the same language provided in Part 4., Item Number 1.b.; I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., item Number 1.b.; and The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question. 6.a. Interpreter's Signature ,which 6.b. Date of Signature (rninidd/yyyy) ► Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparers Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt K Ste. K Flr. 3.c City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 31. Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. K I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent 7.b. K lam an attorney or accredited representative and my representation of the applicant in this case (choose one) extends K does not extend K beyond the preparation of this form. Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when required, supplied additional information to respond to a question on the form. &a. Preparer's Signature &b. Date of Signature (mm/dd/yyyy) ► NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper; type or print your name and 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 date and sign each sheet. Form I-102 12/23/16 N Page 4 of 4 EFTA01699796 Application For Employment Authorization Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-765 OMB No. 1615-0040 Expires 02/28/2018 For USCIS Use Only Fee Stamp Action Block Initial Receipt Resubmitted Relocated Received Sent Completed K Application K Au O Autbotization/Extevsko Subject Approved horization/Extension Valid From O Application Denied - Failed to establish: O Eligibility under O Economic necessity under 8 CFR 274a.12 8 CFR 274a:12(0O4)v (18) (a) or (e) and S CFR 214.20) Approved Denied Valid To AN to the tollo"ing conditions: K Applicant Is tiling under section 274a.12 ► START HERE - Type or print in black ink. I am applying for 9. K Permission to accept employment. K Replacement (of lost employment authorization document). Social Security Number (Include all numbers you have ever used, if any) 10. Alien Registration Number (A-Number) or Form 1-94 K Renewal of my permission to accept employment (attach a copy of your previous employment authorization Number (if any) document). 1. Full Name 11. Have you ever before applied for employment Family Name First Name Middle Name authorization from USCIS? K Yes (Complete the following questions.) Which USCIS Office? Dates 2. Other Names Used (include Maiden Name) Family Name First Name Middle Name Results (Granted or Denied - attach all documentation) K No (Proceed to Question 12.) 3. U.S. Mailing Address 12. Date of Last Entry into the U.S., on or about Street Number and Name Apt. Number (mm/dd/yyyy) 13. Town or City State ZIP Code Place of Last Entry into the U.S. 4. 14. Country of Citizenship or Nationality Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful Status, etc.) 5. Place of Birth Town or City State/Province Country 15. Current Immigration Status (Visitor, Student, etc.) 6. 16. Date of Birth (nun/dcl/yyyy) Eligibility Category. Go to the "Who May File Form I-765?" section of the Instructions. In the space below, place 7. Gender K Male K Female the letter and number of the eligibility ca egory you selected from the instmctions. For example, 8. Marital Status ( K Single K Married K Divorced K Widowed (a)(8), (c)(17)(iii), )(I'M etc. ) Form 1-765 01/17/17 N Page 1 of 2 EFTA01699797 17. (c)(3)(C) Eligibility Category. If you entered the eligibility category (c)(3)(C) in Question 16 above, list your degree, your employees name as listed in E-Vcrify, and your employer's E-Verify Company Identification Number or a valid E-Verify Client Company Identification Number in the space below. Degree Employer's Name as listed in E-Verify Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number 18. (c)(26) Eligibility Category. If you entered the eligibility category (e)(26) in Question 16 above, please provide the receipt number of your H-1B principal spouse's most recent Form I-797 Notice of Approval for Form 1-129. 19. (c)(35) and (eX36) Eligibility Category a. If you entered the eligibility category (c)(35) or (eX36) in Question 16 above, please provide the receipt number of the Form I-140 beneficiary's Form I-797 Notice of Approval for Form I-140. b. Have you EVER been arrested for and/or convicted of any crime? K Yes K No NOTE: If you answered "Yes" to Item Numbers 19.b., refer to Item Number 5., Item H. or Item I. in the Who May File Form 1-765 section of these Instructions for information about providing court dispositions. Certification I certify, under penalty of perjury, that the foregoing is true and correct. Furthermore, I authorize the release of any information that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. I have read the "Who May File Form I-765?" section of the instructions and have identified the appropriate eligibility category in Question 16. Applicant's Signature Date of Signature (mm/dd/yyyy) Telephone Number Signature of Person Preparing Form, If Other Than Applicant I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge. Preparer's Signature Date of Signature (mm/dd/yyyy) Printed Name Address Form1-765 01/17/17 N Page 2 of 2 EFTA01699798 CONTINUED PRESENCE REQUEST PROCEDURES Listed below are all the documents necessary for Parole and Humanitarian Assistance Branch, Office of International Affairs at INS to approve requests for continued presence. One set of all documents listed in items 1-6 must be completed/provided by the SA for each victim of a severe form of trafficking, including juveniles. Once complete, the documents need to be forwarded to Melody Tiddle, Management/Program Analyst, Office for Victim Assistance at FBIHQ, Room 3329 who will complete the Law Enforcement Agency Certificate (Item #7) and forward the entire packet to PHAB, via FedEx. 1. Request for Continued Presence Form (template) (Signed by Case Agent and Supervisor) 2. INS Form I-102 (1-94 departure record) o Signed by Victim o Address — In care of: Case Agent's Name and Address o Original must be Submitted 3. INS Form 1-765 (employment authorization = EAD) o Signed by Victim o Item #3, do: Case Agents Name and Address o Original must be Submitted 4. 2 passport type photos (white background, glossy, unmounted, 2x2 full face photos) 5. 2 sets of fingerprints 6. Copy of the criminal records check 7. Law Enforcement Agency certification — Completed by OVA Please be sure to indicate within your submission the intended prosecutorial source of the case (categories below): • The US Attorney's Office, District, is handling the case and has concurred with this request. • The US Department of Justice, Criminal Division, Child Exploitation and Obscenity Section (CEOS), is handling the case and has concurred with this request; • The US Department of Justice, Civil Rights Division, Criminal Section, is handling the case and has concurred with this request; • The US Department of Justice, Criminal Division, Organized Crime and Racketeering Section is handling the case and has concurred with this request. • Other (please list) EFTA01699799 8/7/2013 CONTINUED PRESENCE EXTENSION REQUEST PROCEDURES It is the responsibility of the Case Agent to put tickler in file regarding CP Extensions. Requests for extension of continued presence must be submitted 30 days prior to the expiration of the individual's 1-94. When requesting an extension for continued presence, the SA must submit the following materials to OVA: 1. Request for Extension of Continued Presence Form (Template) 2. INS Form 1-765 (employment authorization = EAD) o Signed by Victim o Item #3, c/o: Case Agent's Name and Address o Original must be Submitted 3. INS Form 1-102 (I-94 departure record) Signed by Victim o Address — In care of•. Case Agents Name and Address o Original must be Submitted 4. 2 passport type photos (white background, glossy, unmounted, 2x2 full face photos) 5. Copy of the criminal records check 6. Law Enforcement Agency certification — Completed by OVA Once completed, SA is to forward the completed Request for Extension of Continued Presence Packet to Melody Tiddle, Management/Program Analyst, Office for Victim Assistance at FBIHQ, Room 3329 who will complete the Law Enforcement Agency Certificate and forward the entire packet to PHAB, via FedEx. EFTA01699800 8/7/2013 EFTA01699801