PERSONAL STATEMENT/DECLARATION IN SUPPORT OF

APPLICATION FOR T NONIMMIGRANT STATUS (T-VISA)

CONFIDENTIALITY NOTICE

THIS DOCUMENT CONTAINS SENSITIVE INFORMATION

Information contained in this T-Visa application is confidential and protected under 8 U.S.C. § 1367. This information may not be disclosed except as authorized by law.

DECLARATION OF [APPLICANT NAME]

I, [FULL LEGAL NAME], hereby declare under penalty of perjury under the laws of the United States of America that the following is true and correct:

I. PERSONAL INFORMATION

II. ELIGIBILITY REQUIREMENTS

To qualify for T nonimmigrant status, I must demonstrate that:

☐ I am or was a victim of a severe form of trafficking in persons
☐ I am physically present in the United States, American Samoa, CNMI, or at a port of entry due to trafficking
☐ I have complied with reasonable requests for assistance from law enforcement (or qualify for an exception/exemption)
☐ I would suffer extreme hardship involving unusual and severe harm if removed

III. TYPE OF TRAFFICKING

A. Definition of Trafficking

"Severe forms of trafficking in persons" under 22 U.S.C. § 7102 means:

Sex Trafficking: The recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a person for the purpose of a commercial sex act, in which the commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age.

Labor Trafficking: The recruitment, harboring, transportation, provision, or obtaining of a person for labor or services through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery.

B. Type of Trafficking I Experienced

☐ Sex Trafficking
☐ Labor Trafficking
☐ Both Sex and Labor Trafficking

IV. DETAILED NARRATIVE OF TRAFFICKING EXPERIENCE

INSTRUCTION: Please provide a detailed, chronological account of your trafficking experience. Include how you were recruited, what happened during the trafficking, how it ended, and where you are now.

A. Recruitment and Initial Contact

How I Was Recruited:

1. Date/Time Period: [APPROXIMATE DATE OR TIME PERIOD]

2. Location: [WHERE RECRUITMENT OCCURRED]

3. Recruiter(s): [DESCRIBE WHO RECRUITED YOU - use pseudonyms if names unknown]

4. Method of Recruitment:
   ☐ Job advertisement
   ☐ Personal contact/introduction
   ☐ Family member involvement
   ☐ Romantic relationship
   ☐ Social media
   ☐ Other: [DESCRIBE]

5. What I Was Promised:
   [DESCRIBE WHAT THE TRAFFICKERS TOLD YOU - e.g., job opportunity, better life, education, marriage, etc.]

6. How I Was Deceived:
   [EXPLAIN THE DIFFERENCE BETWEEN WHAT WAS PROMISED AND WHAT ACTUALLY HAPPENED]

B. Transportation/Movement

How I Came to Be in the United States:

1. Country of Origin: [COUNTRY]

2. Transit Countries: [LIST ANY COUNTRIES TRAVELED THROUGH]

3. Method of Entry to U.S.:
   ☐ By air
   ☐ By land
   ☐ By sea
   ☐ Other: [DESCRIBE]

4. Documents Used:
   ☐ My own passport
   ☐ Fraudulent documents provided by traffickers
   ☐ No documents
   ☐ Other: [DESCRIBE]

5. Who Controlled My Travel:
   [DESCRIBE WHO ARRANGED AND CONTROLLED YOUR TRAVEL]

6. Date of Arrival in U.S.: [DATE OR APPROXIMATE DATE]

7. Location of Arrival: [CITY, STATE OR PORT OF ENTRY]

C. The Trafficking Situation

Description of What Happened After Arrival:

1. Where I Was Taken/Held:
   [DESCRIBE LOCATIONS WHERE YOU WERE HELD OR WORKED]

2. Who Controlled Me:
   [DESCRIBE THE TRAFFICKER(S) - may use pseudonyms]
   - Physical description:
   - Relationship to you:
   - Role in trafficking operation:

3. What I Was Forced to Do:

For Labor Trafficking:
☐ Domestic work
☐ Agricultural work
☐ Restaurant/food service
☐ Factory work
☐ Construction
☐ Nail salon/beauty
☐ Massage parlor
☐ Janitorial/cleaning
☐ Begging
☐ Other: [DESCRIBE]

[DESCRIBE YOUR WORKING CONDITIONS:
- Hours worked per day/week
- Pay received (if any)
- Living conditions
- Food/medical care provided
- Freedom of movement]

For Sex Trafficking:
☐ Prostitution
☐ Escort services
☐ Pornography
☐ Strip clubs
☐ Massage parlor
☐ Online exploitation
☐ Other: [DESCRIBE]

[DESCRIBE YOUR SITUATION - provide as much detail as you are comfortable sharing]

D. Force, Fraud, and Coercion

The Traffickers Used the Following Methods to Control Me:

Force (Physical):
☐ Physical violence/beatings
☐ Sexual assault
☐ Restraint/confinement
☐ Denial of food/water
☐ Denial of medical care
☐ Other: [DESCRIBE]

[PROVIDE SPECIFIC EXAMPLES WITH DATES IF POSSIBLE:]

Fraud (Deception):
☐ False promises about work
☐ False promises about pay
☐ False promises about living conditions
☐ False promises about legal status
☐ Other: [DESCRIBE]

[DESCRIBE HOW YOU WERE DECEIVED:]

Coercion (Threats and Psychological Control):
☐ Threats of violence against me
☐ Threats of violence against my family
☐ Threats of deportation
☐ Threats to report to police
☐ Debt bondage
☐ Confiscation of documents
☐ Isolation from others
☐ Constant surveillance
☐ Psychological manipulation
☐ Other: [DESCRIBE]

[DESCRIBE THE THREATS AND PSYCHOLOGICAL CONTROL:]

E. Debt Bondage (If Applicable)

☐ I was subjected to debt bondage

1. Initial "Debt" Claimed: $[AMOUNT]

2. What the Debt Was For:
   ☐ Transportation costs
   ☐ Housing
   ☐ Food
   ☐ Smuggling fees
   ☐ Recruitment fees
   ☐ Other: [DESCRIBE]

3. How Debt Increased:
   [DESCRIBE HOW THE TRAFFICKERS ADDED TO YOUR DEBT]

4. Wages Withheld:
   [DESCRIBE HOW WAGES WERE TAKEN OR WITHHELD]

F. Document Control

☐ My documents were taken or controlled by the traffickers

Documents Taken:
☐ Passport
☐ Identification documents
☐ Birth certificate
☐ Work permits
☐ Other: [DESCRIBE]

[EXPLAIN WHEN AND HOW YOUR DOCUMENTS WERE TAKEN]

G. Freedom of Movement

☐ My freedom of movement was restricted

Restrictions Included:
☐ Locked in location
☐ Guarded/watched constantly
☐ Not allowed to leave alone
☐ Not allowed to contact family
☐ Not allowed to use phone
☐ Threats if I tried to leave
☐ Other: [DESCRIBE]

H. How the Trafficking Ended

How I Escaped/Was Freed:

1. Date: [DATE OR APPROXIMATE DATE]

2. How It Happened:
   ☐ I escaped on my own
   ☐ Law enforcement raid/rescue
   ☐ Good Samaritan helped me
   ☐ Traffickers released me
   ☐ I was able to contact help
   ☐ Other: [DESCRIBE]

[PROVIDE DETAILS OF HOW YOU GOT OUT:]

3. Where I Went After:
   [DESCRIBE WHERE YOU WENT AND WHO HELPED YOU]

V. COMPLIANCE WITH LAW ENFORCEMENT

A. Contact with Law Enforcement

☐ I have reported the trafficking to law enforcement
☐ I have cooperated with law enforcement
☐ I have not had contact with law enforcement (see exemption below)

If Contact with Law Enforcement:

B. LEA Endorsement (Form I-914 Supplement B)

☐ I have obtained Form I-914 Supplement B (Declaration for Trafficking Victim)
☐ I am submitting alternative evidence of compliance (see below)
☐ I qualify for an exemption from the compliance requirement

Note: Form I-914 Supplement B is NOT required, but it is helpful evidence.

C. Exemption from Compliance Requirement

☐ I was under 18 at the time of the trafficking (no compliance required)
☐ I experienced trauma that prevents compliance (explain below)

[IF CLAIMING EXEMPTION, EXPLAIN:]

VI. PHYSICAL PRESENCE IN UNITED STATES

I am physically present in the United States due to the trafficking because:

☐ I was trafficked into the United States
☐ I was trafficked within the United States
☐ I was freed from trafficking in the United States
☐ I was brought to the U.S. to participate in investigation/judicial process

VII. EXTREME HARDSHIP

Removal from the United States would cause me extreme hardship involving unusual and severe harm because:

A. Fear of Traffickers

[DESCRIBE WHY YOU FEAR THE TRAFFICKERS IF RETURNED:
- Threats made
- Power/reach of traffickers
- Likelihood they could find you
- What they would do]

B. Country Conditions

[DESCRIBE CONDITIONS IN YOUR HOME COUNTRY:
- Lack of protection from traffickers
- Re-trafficking risk
- Social stigma
- Lack of services for trafficking victims
- Government response to trafficking]

C. Psychological Harm

[DESCRIBE PSYCHOLOGICAL IMPACT:
- Trauma symptoms
- Mental health conditions
- Need for continued treatment
- Impact of return on mental health]

D. Physical Harm

[DESCRIBE ANY PHYSICAL CONDITIONS:
- Injuries from trafficking
- Need for medical treatment
- Availability of treatment in home country]

E. Other Hardship Factors

[DESCRIBE ANY OTHER FACTORS:
- Family situation
- Economic hardship
- Reintegration difficulties
- Social/community factors]

VIII. FAMILY MEMBERS

A. Derivative T-Visa Applicants

I am including the following family members in my T-Visa application:

For Principal Applicants 21 or Older:
☐ Spouse
☐ Children (unmarried, under 21)

For Principal Applicants Under 21:
☐ Spouse
☐ Children (unmarried, under 21)
☐ Parents
☐ Unmarried siblings under 18

B. Family Members at Risk

☐ Family members have been threatened or harmed by traffickers

[DESCRIBE:]

IX. SUPPORTING EVIDENCE

I am submitting the following evidence with my application:

A. Evidence of Trafficking

☐ Law enforcement reports
☐ Court records
☐ News articles
☐ Medical records
☐ Photographs
☐ Communications/messages
☐ Employment records
☐ Travel documents
☐ Affidavits from witnesses

B. Evidence of Compliance with LEA

☐ Form I-914 Supplement B
☐ Police reports
☐ Correspondence with law enforcement
☐ Victim advocate letters

C. Evidence of Extreme Hardship

☐ Country conditions evidence
☐ Psychological evaluation
☐ Medical records
☐ Expert declarations

D. Identity Documents

☐ Passport
☐ Birth certificate
☐ Other ID

X. CURRENT STATUS AND NEEDS

A. Current Safety

☐ I am currently safe from traffickers
☐ I have ongoing safety concerns: [EXPLAIN]

B. Support Services

☐ I am receiving services from: [ORGANIZATION]
☐ I am receiving counseling/therapy
☐ I have safe housing
☐ I need: [DESCRIBE NEEDS]

XI. ADDITIONAL INFORMATION

[INCLUDE ANY OTHER INFORMATION RELEVANT TO YOUR APPLICATION]

XII. DECLARATION

I, [FULL LEGAL NAME], declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge.

I understand that providing false information may result in denial of my application and possible criminal prosecution.

I have reviewed this declaration [and had it translated/read to me in [LANGUAGE]] and affirm its accuracy.

Signature: _______________________________

Printed Name: [FULL LEGAL NAME]

Date: [DATE]

INTERPRETER CERTIFICATION (If Applicable)

I, [INTERPRETER NAME], certify that I am fluent in English and [LANGUAGE]. I translated this declaration to [APPLICANT NAME] in [LANGUAGE], and [he/she] affirmed its accuracy.

Signature: _______________________________
Printed Name: [NAME]
Language: [LANGUAGE]
Date: [DATE]

PREPARER CERTIFICATION

I, [PREPARER NAME], prepared this declaration. I certify that this declaration accurately reflects the information provided by the applicant.

Signature: _______________________________
Printed Name: [NAME]
Date: [DATE]

IMPORTANT INFORMATION

Filing Fee: There is NO fee for Form I-914

Where to File: USCIS Vermont Service Center

Employment Authorization: File Form I-765 concurrently for employment authorization. USCIS may grant bona fide determination and work authorization while case is pending.

Resources:
- National Human Trafficking Hotline: 1-888-373-7888
- USCIS T-Visa Information: www.uscis.gov/t-visa

This template is provided for informational purposes only and does not constitute legal advice. T-Visa applications involve extremely sensitive matters. Applicants are strongly encouraged to seek assistance from a qualified immigration attorney or accredited representative experienced in trafficking cases.