Supplement B, Delaration of Law Enforcement Officer for Victim of Trafficking in Persons Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-914 OMB No. 1615-0099 Expires 12/31/2023 START HERE - Type or print in ink. This form should be completed by Federal, state, local, or tribal law enforcement agencies for victims under the Victims of Trafficking and Violence Protection Act (VTVPA). Public Law 106-386. as amended. PART 1. Victim Information 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if any) 2. Other Names Used 3. 5. 6. Provide any other names you have used since birth, including aliases, maiden names, and nicknames. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name (if any) Date of Birth (ddirrun/yyyy) 4. Gender or Sex El Male El Female El Other Alien Registration Number (A-Number) (if any) P. A- U.S. Social Security Number (SSN) (if any) .r Part 2. Agency Information 1. Name of Certifying Agency Federal Bureau of Investigations 2. Name of Certifying Official 3. Title of Certifying Official 4. Division/Office of Certifying Official 5. Agency Mailing Address Street Number and Name For USCIS Use Only Returned Date Date Resubmitted Date Date Reloc Sent Date Date Reloc Rec'd Date Date Receipt Remarks 26 Federal Plaza City or Town (ILSPI VP rode Lank -A Apt. Ste. Flr. Number 0 0 El State ZIP Code NY New York 6. Daytime Telephone Number 7. Fax Number 102711 Form 1-914. Supplement B Edition 12/C0/21 Page I EFTA00156636