Inter-Agency Alien Witness and Informant Record

• Legal Form Number: I-854
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-854A Edition 11/08/21 Page 1 of 8

USCIS

Form I-854A

OMB No. 1615-0046

Expires 11/30/2024

Inter-Agency Alien Witness

and Informant Record

Department of Homeland Security

U.S. Citizenship and Immigration Services

Part 1. To be completed by Law Enforcement Agencies (See instructions for specific information.)

START HERE - Type or print in black ink.

2. Control Agent

E-mail Address

3. Mailing Address

City or Town State ZIP Code

Street Number and Name Flr.Ste.Apt.

Daytime Telephone Number

4. Contact Information

Fax Number

5. Select all applicable boxes.

6. Type of Requests. (Attach legal basis for request.)

NOTE: Provide a clear statement of the operations that form the basis of the request (e.g., Grand Jury subpoena), the objective of

the request, and any bargain the LEA wishes to make or has made with the alien. Attach a complete criminal history, FBI

Number, and U.S. Social Security Number (if applicable). Include any security concerns and special instructions regarding

security precautions.

As a result of providing information, the alien will be placed in danger: abroad. in the United States or

If the alien poses a danger, the danger posed by the alien is outweighed by the assistance the alien will furnish.

Investigation. Prosecution. United States Attorney involvement.

S-5 S-6 Consular post at which visa will be sought:S-7

7.

Family Name (Last Name) Given Name (First Name) Middle Name

A. Alien's Current Legal Name (do not provide a nickname)

B.

Family Name (Last Name) Given Name (First Name) Middle Name

1. Name of Law Enforcement Agency (LEA)/Requestor

Requesting Agent (Special Agent in Charge, Chief of Police, etc.)

In the space below, provide all the requested information for the alien for whom an S classification is requested.

Other Names Alien Has Used Since Birth (include nicknames, aliases, and maiden name, if applicable)

The alien poses no danger to people or property of the United States.