Supplement 8, Delaration of Law Enforcement Officer for Victim of Trafficking in Persons Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form 1-914 OMBNo.1615-0099 Expires 1//31/2023 START HERE - Type or print in ink. This form should be completed by Federal, state. local, or tribal law enforcement agencies for victims under the Victims of Trafficking and Violence Protection Act (VTVPA). Public Law 106-386, as amended. PART 1. Victim Information I. Full Legal Name Family Name (Last Name) Given Maine (Pint Name) Middle Name (if any) 2. Other Names Used Provide any other names you have used since birth, including aliases. maiden names. and nicknames. If you need extra space to complete this section. use the space provided in Part 9. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name (if any) 3. Date of Binh (dd/mm/yyyy) 4. Gender or Sex 02/21/1985 K Male Female K Other 5. Alien Registration lo• A- Number (A-Number) (if any) 6. U.S. Social Security Number (SSN) (if any) Part 2. Agency Information I. 2. 3. 4. 5. 6. Name of Certifying Agency Federal Bureau of Investigations Name of Cenifying Official Title of Certifying Official Special Agent Division/Office of Certifying Official New York Field Office Agency Mailing Address Street Number and Name 26 Federal Plaza City or Town New York Daytime Telephone Number 7. Fax Number For USCIS Use Only Returned Date Date Resubmitted Date Date Reloc Sent Date Date Reloe Rec'd Date Date Receipt Remarks amszitssies Apt. Ste. Flr. Number El State ZIP Code NY 10278 Form 1-914. Supplement B Edition 12/0281 Page I EFTA00151754