Part 5. Family Members Culpable In Criminal
Activity

 

 

 

I. Are any of the victim?s l'amily members culpable or
believed to be culpable in the criminal activity of which

'13
thtll'you answered "Yes." list the family members and their
criminal involvement. (llyou need extra space to
complete this section. use the space provided in Part 7.
Additional Information.)

 

2.3. Family Name 
{Last Namel

Lb. Given Name
{First Name]

2.e. Middle Name

 

 

 



 

2.d. Relationship

7

Le. Involvement

3.a. Family Name 
(LastName)

lb. GivenName 
lFirstName]

 

 

 

 

 

 

 



3.d. Middle Name 

3.d. Relationship

involvement

4.3. Family Name 
(Last Name)
4.b. Given Name
[First Name}

Middle Name if

 

 

 

 

 

 

 

 

4.d. Relationship



4.e. Involvement



 

lPart 6. Certi?cation

 

 

I am the head ol?the agency listed in Part 2. or am the person
in the agency who was speci?cally designated by the head ol-
the agency to issue a Nonimmigrant Status Certi?cation on
behalt?oi?the agency. Based upon investigation ot?the facts. I
certify. under penalty of perjury. that the individual identi?ed in
Part I. is or was a victim clone or more ol? the crimes listed in
Part 3. I certify that the above inibrrnation is complete. true.
and correct to the best of my knowledge. and that have made
and will make no promises regarding the above victim's ability
to obtain a visa from U.S. Citizenship and Immigration Services
(USCIS). based upon this certi?cation. I further certify that it?
the victim unreasonably refuses to assist in the investigation or
prosecution ofthe qualifying criminal activity of which he or
she is a victim. I will notify USCIS.

1. Signature of Certi ly'ing?lleial?



3. Daytime Telephone Number



4. Fax Number



?Fill tE?Q-d?q?? 0.4 Di 9
PCS SIST Tita- .

2. Date of Signature 

 

 

 

Form l-9l3 Supplement 

Page 4 ot'S