EFTA01699742

a EFTA01699742 U.S. Department of Justice United States Attorney Southern District ofNew York The Silvio J. Mono Building One Saint Andrew} Plcca New York New York 10007 June 15,2020 BY FAX lo= To whom it may concern: Please be advised that the accompanying grand jury subpoena has been issued in connection with an official criminal investigation of a suspected felony being conducted by a federal grand jury. The Government hereby requests that you voluntarily refrain from disclosing the existence of the subpoena to any third party. While you are under no obligation to comply with our request, we are requesting you not to make any disclosure in order to preserve the confidentiality of the investigation and because disclosure of the existence of this investigation might interfere with and impede the investigation. If you intend to disclose the existence of this Grand Jury Subpoena request to a third party, please let me know before making any such disclosure. Thank you for your cooperation in this matter. Sincerely, GEOFFREY S. BERMAN United States Attorney By: "A_ - - Assistant United States Attorney Telephone: EFTA01699743 INIIMms. EFTA01699744 Grand Jury Subpoena PnitetroStatesPiztrict Court SOUTHERN DISTRICT OF NEW YORK TO: AT&T Wireless Legal Compliance 11760 Highway 1, Suite 600 North Palm Beach, FL 33408 GREETINGS: WE COMMAND YOU that all and singular business and excuses being laid aside, you appear and attend before the GRAND JURY of the people of the United States for the Southern District of New York, at the United States Courthouse, 40 Foley Square, Room 220, in the Borough of Manhattan, City of New York, New York, in the Southern District ofNew York, at the following date, time and place: Appearance Date: July 6, 2020 Appearance Time: 10:00 a.m. to testify and give evidence in regard to an alleged violation of : 18 U.S.C. §§ 1591, 1594(c), 2423(a), 2422(b) and not to depart the Grand Jury without leave thereof, or of the United States Attorney, and that you bring with you and produce at the above time and place the following: See Attached Rider Personal appearance is not required if the uested records are (1) roduced by on or before the return date to Special Agent , telephone: or via email at ; and (2) accompanied by an executed copy of the attached Declaration of Custodian of Records. PLEASE PROVIDE IN ELECTRONIC FORMAT IF POSSIBLE. Failure to attend and produce any items hereby demanded will constitute contempt of court and will subject you to civil sanctions and criminal penalties, in addition to other penalties of the Law. DATED: New York, New York June 15, 2020 GEOFF E .GERMAN United States Attorneyfor the Southern District ofNew York Assistant United States Attorney One St. Andrew's Plaza New York, New York 10007 Telephone: EFTA01699745 RIDER (Grand Jury Subpoena to AT&T. dated June 15. 2020) Please provide any and all records (including, but not limited to, incoming and outgoing calls with any call details, local and long distance usage details, all subscriber opening and/or registration documents, all subscriber identification and contact information, all subscriber billing and payment information, SMS/text messaging records, IP history and login records, associated email addresses and/or screen names, and any additional accounts associated with any of the below-listed names, identifiers, addresses, phone numbers, and accounts listed and associated records for those accounts) relating to the following telephone numbers, as listed below, for the time period of March I, 2020 to the present: • N.B.: Personal appearance is not required if the requested records are (1) produced by on or before the return date to Special , telephone: or via email at and (2) accompanied by an executed copy of the attached Declaration of Custodian of Records. PLEASE PROVIDE IN ELECTRONIC FORMAT IF POSSIBLE. IMPORTANT: REQUEST FOR NON-DISCLOSURE Due to the ongoing nature of the investigation, it is requested that you do not disclose any information relating to this Crand Jury subpoena request to any third party. EFTA01699746 Declaration of Custodian of Records Pursuant to 28 U.S.C. § 1746, I, the undersigned, hereby declare: My name is (name of declarant) I am a United States citizen and I am over eighteen years of age. I am the custodian of records of the business named below, or I am otherwise qualified as a result of my position with the business named below to make this declaration. I am in receipt of a Grand Jury Subpoena. dated June 15, 2020. and signed by Assistant United States Attorney . requesting specified records of the business named below. Pursuant to Rules 902(1I) and 803(6) of the Federal Rules of Evidence, I hereby certify that the records provided herewith and in response to the Subpoena: (1) were made at or near the time of the occurrence of the matters set forth in the records, by, or from information transmitted by, a person with knowledge of those matters; (2) were kept in the course of regularly conducted business activity; and (3) were made by the regularly conducted business activity as a regular practice. I declare under penalty of perjury that the foregoing is true and correct. Executed on (date) (signature of declarant) (name and title of declarant) (name of business) (business address) Definitions of terms used above: As defined in Fed. R. Evid. 803(6), "record" includes a memorandum, report, record, or data compilation, in any form, of acts, events, conditions, opinions, or diagnoses. The term, "business" as used in Fed. R. Evid. 803(6) and the above declaration includes business, institution, association, profession, occupation, and calling of every kind, whether or not conducted for profit. EFTA01699747 r PERSONAL IDENTIFICATION F0443 (R SEE REVERSE SIDE FOR F LW HER NS'RuCTIONS 4413) LAS NAM L INFORM/G:0N IN BLACK FIRST NAME MIDDLE MME FIN LEAVE BLANK SIOPNWRE OF PERSON FINGEPPRNTIO ARROFTS SUBMITTED BY RE90ENCE OF PERSCN RPRIPITEO GATEOF SRTN DO 'Arit De, 'Ps F N N71 140 G BLN LF DUE FINGERPRICED X RAC HOT RGT EYES HAIR PLACE OF OATH Foe •tigrom BE NOTWIEC M CASE OF ELERGERCY RAW LEAVE BLANK %CC14 SECURITY ADORE SS IASCELLANEOUS SO Non -Federal Confidential Screening FINCER• 4 %' SCARS AP, R THuia SR 6L THUMB I 7 LEFT [VA APP:414STAPIN SPAILLANCOUSt+ I I TALUS I ft PAPPAS iti]Aff co. CP4C4RI 'WENlativti•MOUtix EFTA01699748 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1. Use printer's ink. 2 Distribute ink evenly on inking slab 3. Wash and dry lingers thoroughly 4. Roll fingers from nail to nail, and avoid allowing lingers to shp. 5. Be sure impressions are recorded in correct order. 6. Notate in the appropriate linger blocks if applicant is missing one or more lingers for any reason. II not missing. all ten impressions must be provided with scars and deformities notated. 7. If some physical condition makes it impossible to obtain perfect impressions, submit the best that can be obtained 8. Examine the completed prints to see if they can be classified. bearing in mind the following: Most fingerprints fall into the patterns shown below Other patterns occur tnirequently and are not shown here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes. State statutes pursuant to Pub.L. 92-544, Presidential Executive Orders, and federal PASTE regulations. Providing your fingerprints and associated information is voluntary: however, failure to do so may affect completion or approval of your application. PHOTO HERE Principal Purpose: Certain determinations, such as employment, licensing, and (OPTIONAL) security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained. your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated informatiorVbiometrics are retained in NGI, your information may be disclosed pursuant to your consent. and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment. contracting, licensing, security clearances, and other suitable determinations: local, state, tribal, or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety FD-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:OW.02017 11:5138 EFTA01699749 r PERSONAL IDENTIFICATION : EE REVERSE SIDE FOR FukTHER iNSTRuC - IONS FD-3.43(Ret 94131 LAST NAME NAM INFORMATION IN BLACK FIRST NAME MCDI NAE/I rd LEAVE CLANK SIGNATURE Of IERSON FINGERPRINTED FINGERPRINTS SUMAITTED BY A't OF OREN DOB RESCENCE OF PERSON FINGERPREITED Akre) 0e As F W N71 140 G BLN LP DATE FIAGERPRIICE0 sot RACE "GT ATSI EYES MAR RACE a SETH ROB Pia NOTIFIED N CASE CF ELERGENCY LEAVE BLANK WAG AlEsai ISCiAnTY ADDEESS IESCELIAPEOUS NO Non -Federal Confidential Screening FAEGERPRINTED BY REF SCARS AND BERES LZIT rocinFINCERIVAAEN EINIAATECOvrAy R Tit*. MOTT FODA CNCEffitt TAKEN SAAA.TAASOutte EFTA01699750 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1. Use printers ink. 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly. 4. Roll fingers from nail to nail. and avoid allowing fingers to slip. 5. Bo sure impressions are recorded in correct order. 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. II not missing, all ten impressions must be provided with scars and deformities notated. 7. If some physical condition makes it impossible to obtain perfect impressions. submit the best that can be obtained. B. Examine the completed prints to see if they can be classified. bearing in mind the following: Most fingerprints fall into the patterns shown below Other patterns occur infrequentty and are not shown here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders. and federal PASTE regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. PHOTO HERE Principal Purpose: Certain determinations, such as employment. licensing, and (OPTIONAL) security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of Comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and. while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI. your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register. including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include. but are not limited to, disclosures to: employing, govemmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitable determinations: local, state. tribal. or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety FD-3.43 (Rev. 9-9-i3) U.B. GOVERNMENT PUBLISHING OFFICE:OB/244017 I 1:53.38 EFTA01699751 I PERSONAL IDENTIFICATION SEE REVERSE SCE FOR FURTHER INSTRUCTIONS F0-353(R•494471 I LIST."( NAM ALL INFORMATION IN BLACK FIRST WAIF MICC“ AM FBI LEAVE BLANK IGNATURE OF PERSON FINGERPRPin0 F RPRINTS Su/Uri-ED Iv DATE Of BOTH BOB REYLENCE CF PERSON FIHGERPRNTEO ma. O., New F W N71 140 G BLN LP DATE IlsGERPRIN'E0 x I RAC At, Ens PIACE BM). ROB TO CE NOTFIED IN CASE EN£RGENC 'LOAF SOCI.LL fECWITv LEAVE BLANK ANSIXESS CUSS Et LAREOUS NO Non -Federal Confidential Screening FIPItINTED SCARS Ax. an ran r inKCIISTAXEm SikOATANCOJS0' R TtiWO EFTA01699752 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION. CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerprints 1 Use printer's ink 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly 0 Roll fingers from nail to nail, and avoid allowing fingers to slip. 5. Ete sure impressions are recorded in correct order 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. If not missing. all ten impressions must be provided with scars and deformities notated 7 If some physical condition makes ❑ impossible to obtain perfect impressions. submit the best that can be obtained 8 Examine the completed prints to see if they can be classified. bearing in mind the following. Most fingerprints fall into the patterns shown below Other patterns occur infrequently and are not shown here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders, and federal PASTE regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. PHOTO HERE Principal Purpose: Certain determinations, such as employment, licensing, and (OPTIONAL) security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil. criminal, and latent fingerprint repositories) or other available records of the employing investigating. or otherwise responsible agency. The FBI may retain your fingerprints and associated informationlbiometrics in NCI after the completion of this application and. while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitable determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies: and agencies responsible for national security or public safety Ft)-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:0121/2017 11:5138 EFTA01699753 I PERSONAL IDENTIFICATION '_ EE REVERSE SIDE FOR FURTHER INSTRUCTIONS FP-353 (Rev 94431 LAST NYE NAM INFORMATIONIABLACK FIRST NAME MCGEE NAPE rg LEAVE BLANK MATURE OF PERSON MGM:PROOFS MIGERPRINTS SLORTTED BY DA OF EIRl DO: PC OF PERSON FINGERMINTED ee.. 0 V... P M N71 140 G BLN LP DATE FINGERPRINTED RACE NOT MGT EYES NAN PUCE OF ORM RCS PEIMVOTIFED N CASE OF MERGERS War LEAVE BLANK SOME S MERRY NO ADORE SS ELLANEOVS NO Non-Poderal Confidential Ccroening I'm:ER/MINTED BY EF SCARS MD MARKS EFTA01699754 FEDERAL BUREAU OF INVESTIGATION UNITED STATES DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306 PERSONAL IDENTIFICATION To obtain classifiable fingerer 1. Use printer's ink. 2. Distribute ink evenly on inking slab 3. Wash and dry fingers thoroughly. 4. Roll ringers from nail to nail, and avoid allowing fingers to slip. 5. Be sure impressions are recorded in correct order. 6. Notate in the appropriate finger blocks if applicant is missing one or more fingers for any reason. If not missing, all ten impressions must be provided with scars and deformities notated 7. II some physical condition makes it impossible to obtain period impressions, submit the best that can be obtained 8. Examine the completed prints to see if they can be classified. bearing in mind the following Most fingerprints fall into the patterns shown below Other patterns occur infrequently and are not slytian here FD-353 Personal Identification Privacy Act Statement Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your applicafion, supplemental authorities include Federal statutes. State statutes pursuant to Pub.L. 92-544. Presidential Executive Orders, and federal PASTE regulations. Providing your fingerprints and associated information is voluntary: however, failure to do so may affect completion or approval of your application. PHOTO HERE Principal Purpose: Certain determinations, such as employment. licensing, and (OPTIONAL) security clearances. may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil. criminal, and latent fingerprint repositories) or other available records of the employing investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometncs are retained in NGI. your information may be disclosed pursuant to your consent. and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include. but are not limited to. disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting. licensing, security clearances, and other suitable determinations: local, state, tribal, or federal law enforcement agencies: criminal justice agencies: and agencies responsible for national security or public safety FD-353 (Rev. 9-9-13) U.S. GOVERNMENT PUBLISHING OFFICE:Orta4/2017 liStge EFTA01699755 Attachment A CERTIFICATION FOR CONTINUED PRESENCE BY REQUESTING LAW ENFORCEMENT AGENCY TO: Unit Chief Parole and Law Enforcement Programs Unit Homeland Security Investigations U.S. Immigration and Customs Enforcement FROM: SAC FBI, New York Field Office RE: Request for Continued Presence for: SAC of the FBI New York Field Office concur in this request and certify, in accordance with the Department of Homeland Security (DHS)'s procedures for Continued Presence, that: 1. The justification and information concerning the request for Continued Presence are accurate and complete. 2. Documentation is attached certifying that the alien is a victim of a severe form of trafficking and may be a potential witness to that trafficking. 3. Name checks have been completed in the principle law enforcement databases on the person named in the request (National Crime Information Center and any other databases available) and, as appropriate, information from foreign law enforcement agencies. Criminal history check results based on fingerprints have been received and any identification issues resolved. [For. the.FBI: Coordination.has also been effected with appropriate member agencies of theintelligence Community.' 4. Copies of all database screens on the person named above, including negative responses, have been identified and forwarded to U.S. Immigration and Customs Enforcement, Homeland Security Investigations, Parole and Law Enforcement Programs Unit. 5. No promises have been made to the Victim that he or she will remain in the United States beyond the authorized period of Continued Presence. 6. An active investigation is underway by a law enforcement agency that requires the assistance of this subject. Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01699756 Signature [of Authorizing Official] Date Printed Name [of Authorizing Official] Title [of Authorizing Official] Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01699757 DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE N.3:7 1bartA: InforatatiOnon'theitiopm. -.72.44t' > ;a14cir iCPIAC:' 1. Name: (Last) (First) (Middle) 2. Date of Birth (mo., day, yr.) 3. Country of Birth 4. Country of Citizenship 6. Allas(es) 6. Gender (check one) 7. Alien Number (A#) Male J Female A 8. Passport Number 9. Country of Issuance 10. Expiration Date (mo., day, yr.) 08/04/2020 & 05/14/2025 11. Social Security Number iiPartataitoguntifIgiaStieSO: 'Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: 2. Daytime telephone number 3. Fax number (First, Last) (include area code) Ext 2. Case Agent where the Victim resides (if the Victim resides In a Jurisdiction other than that of the Lead Case Agent): (First, Last) 2. Daytime telephone number 3. Fax number (include area code) Ext SupplementalInformation: Requesting Agency: Federal Bureau of Investigation Group Supervisor's name (First, Last) Daytime telephone number (includingarea code) ext. Fax number Victim-Witness Specialiat's/Coordlnator's name (First, Last) Daytime telephone number (Including area code) ext. Fax number Request.for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA01699758 *Note: Please complete allinformation below. 1. Is the Victim currently in.the United States? El Yes O No 2. The Victim's current immigration status: In the U.S. on an E-2 Visa 3. is the Victim requesting Continued Presence based upon a pending,civil action under 18 U.S.C. § 1595? 0 Yes 0 No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? 0 Yes Ej No (if yes, where and when) City, State: 5. When did the Victim enter the United States? 1st Entry 09/0145 6. Through which Port of Entry did the Victim enter the United States? New York, New York 7. How did the Victim enter the United States? Flight oi3/40 5,1* -00,09;**000:00.111M011-0411W Please answer each question as completely as.possible (Attach additional sheet(s), ifnecessary.) 1. Significance and value of the Victim to this case: (please provide a brief explanation ofhow the Victim meets the definition of "severe forin of trafftking" under section 103(8), Victims of Trafficking end Violence Protection Act of 2000, Pub. L. No. 106-388) See attached sheet. 2. The Victim's criminal involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) No criminal convictions. 3. Risk the Victim presents to public safety and/or to national security (i.e., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary: (Attach copy ofrisk assessment report) No risk to public safety or national security 4. Financial responsibility for the Victim: (Please explain mannerin which the Victim's living expenses will be met.) is requesting employment authorization to work in the United States. 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state; attach additional sheet(s), ifnecessary.) No relatives live in the United States. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA01699759 6. Is employment authorization requested? E3 Yes O No (If yes, please attach completed U.S. Citizenship and immigration Services FORM 1-765; Application for Employment Authorization, and 1-102, Application for Replacement/Initial Nonimmigrant Arrival/Departure Document) Note: Information contained in question # 7-is not required for a victim to receive Continued Presence; however, this information is required fora victim to be certified to receive benefits from the Departinent of Health and Human Services (HHS), Office of RefugeeResettlement(ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. Is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. 0 Yes O No 7404; tocation.whete the'Iiistintayinqtielde inWatktkitiiiOarIltigta Street Address City New York State NY *Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for ContinuedPresence must be submitted to the ICE HSIHeadquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reportedto the requesting agency headquarters, which In turn willnotify LEPU. The requesting agency will also notify LEPU Immediately if the alien departs the United States. gfitatt:PrOectifitatiomotRiipOtitidiRiterli r t3fev Tlit-WsceggSylpiai As the requesting agency representative, I understand that, should thls ContinuedPresence be granted, it is MY responsibility to follow all of the policies andprocedures established by LEPU, including quarterly reporting, reporting changes in the Victim's status (Le., departure or change in status), and requesting applicable extensions ofapproved Continued Presence. -7(lo 2-0 na ure) Date) / Supervisory Special Agent me) 1 / I ES 2020 e gen gnature) (Date) / Special Agent (Print Name and Title) if the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (PrintRame and Title) Request for Continued Presence FOR OFFICIAL USE ONLY! LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 3 of 4 EFTA01699760 Privacy Act Statement Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form. ill be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting.law enforcement officedagentand their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared.with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted. under 5 § 552a(b) pursuant to the routine uses published in the Department of Homeland Seturity system of records notice, DHSACE-011 Immigration andEnforcement Operational Records. Disclosure: The discloture of the infortnatien on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of-the request for ContinuedPresence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 4 of 4 EFTA01699761 FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE PART D:1 Jeffrey Epstein abused over several years, beginning when she was 18 years old. It was during the course of this abuse that Epstein brought into some of his massages to participate in sex acts with other girls. Epstein controlled every aspect of -s life—including her physical appearance, her weight, and her clothing—for years. This controlling behavior took multiple abusive forms, including forcing to have multiple plastic surgeries, forcing her to engage in BDSM, referring to her as his "sex slave," insulting her, and physically abusing her, including by choking her and throwing her down a set of stairs. FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE EFTA01699762 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document USCIS Form I-102 Department of Homeland Security OMB No. 1615-0079 U.S. Citizenship and Immigration Services Expires 10/31/2019 Receipt Action Block To Be Completed by an Attorney or Aerredited Representative, if any. For. i ❑ Select this box if Form WOO G-28 is attached to UJe. :i New I-94 Number represent the applicant. I :Otifr• ! Attorney State License Number I . Remarks I. START HERE. Type or print in black ink iPart Inflonkationbnut tow 1. Mien Registration Number (A-Number) La. In Care Of Name le A- 1 1 1 1 1 1 2. LlSaS Online Account Number (if any) Lb. Street Nut and Name 1 1 6.c. Apt. 0 Ste. 0 FIr. 0 FfauaTitionsg e77— 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6L ZJI)Code 3.b. Given Name (First Name) erinformation 3.c. Middle Name 7. Date of Birth (mm/dd/yyyy) ► 41.0iraitu4Spriiiiw77 8. Country of Birth 4.a. In Care Of Name 9. 4.b. Street Number and Name 10. . titer (if any) 4.c. Apt. 2 Ste. 0 Fir. 0 4.d. City or Town 1\16v4 o Entry Inforentizt0th 4.e. State 4.f. ZIP Code MC*5 11. Dale of Last Batty into the United States 5. Is your current U.S. mailing address the same as your (nnliddiTRY) ► U.S. physical address? g Yes 0 No 12. Place of Last Entry Into the United States (City and State) If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.1. LDS *N66LES , CA. Form I-102 10/19/17 N Page 1 of 4 EFTA01699763 Part k., Ihformition About You 0.0116=4 OartJ: :Pro-cessing Information . I3. Current Nonimmigrant Status La. Are you filing this application with any other petition or application? E 2 VI5ft O Yes g No 14. Date Status Expires If "Yes" provide the USCIS Form Number and name of the (mmidd/yyyy) ► 03125/202.1 application or petition you are filing in Item Number Lb. Lb. USCIS Form Number and Name 15.a. Form 1-94,1-94W, o 15.b. Passport Number 2.a. Are you now in removal proceedings? O Yes g No If "Yes" complete Item Number 2.b. 15.c. Travel Document Number Lb. Provide detailed information regarding the proceedings. 15.d. Coun of Issuance for Passport or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper, 15.e. Expiration Date for Passport or T . indicate the Page Number, Part Number, and Item (mrnidd/yyyy) Number to which your answer refers; and date and sign each sheet. Reason ior Applrcation • Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) La. O I am applying to replace my lost or stolen Form I-94 or I.94W. 1.b. ❑ I am applying to replace my lost or stolen Form I-95. Lc. ❑ I am applying to replace my Form I-94 or I-94W because it was mutilated. I have attached my original Form I-94 or I-94W. 1.d. O lam applying to replace my Form 1-95 because it was If you are unable to provide the original of your Form I-94, mutilated. I have attached my original Form I-95. I-94W, or 1-95, provide the following information: to. Ei I was not issued Form I-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form I-94, CBP at a port-of-entry in the United States (whether I-94W, or I-95. at a land border, airport, or seaport). 3.a. Family Name 1.f. El I was issued Form 1-94,1-94W, or I-95 with incorrect (Last Name) infommtion, and I am requesting that USCIS correct the 3.b. Given Name document I have attached my original FormI-94, (First Name) 1-94W, or 1-95. 3.c. Middle Name Lg. O I was not issued Form I-94 when I entered as a 4. Class of Admission at Last Entry into the United States nonimmigrant member of the military, and I am filing this application for an initial Form I-94. E 5. Place of Last Entry into the United States (City and State) LDS Mll e L6S NG\N -PRsspoe-c- Ey laNetk0NI Form I-102 10/19/17 N Pogo 2 of 4 EFTA01699764 -.Taii.4 Stateinent,tlitirlOafiOns;Sitiiiiiiiiiarid. : !Part $: Contact I4formtititin,Certifidatioii, and, :skulitqtjfifOrm4tion,Altke MIppliMpff, Signature of the Interpreter . _ _ NOTE: Select the box for either Item Number la. or 1.b. If Interpreter's Pull Nome applicable, select the box for Item Number 2. 1.a. tgi I can read and understand English, and have read and Provide the following information concerning the interpreter: understand every question and instruction on this 1.a. Interpreter's Family Name (Last Name) form, as well as my answer to every question. Lb. O The interpreter named below has read to me every 1.b. Interpreter's Given Name (First Name) question and instruction on this form, as well as my answer to every question, in 2. Interpreter's Business or Organization Name (if any) a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and:have provided true and correct responses in the language indicated Intelpretet!s Moiling &Ideas, above. 3.a. Street Number 2. O I have requested the services of and consented.to and Name 3.b. Apt. O Ste. O Flr. who is O is not 0 an attorney or accredited 3.e. City or Town representative, preparing this form for me. 3.d. State 3.e. ZIP Code ',241plicturt Cog:main: 3.f. Province I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact 3.g. Postal Code photocopies of unaltered original documents, and I understand that I may be required to submit original 3.h. Country documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to — . determine my eligibility for the benefit that I seek. I int'cripnet.fr.Ss•Cortgtetirtforingthit furthermore authorize release of information contained in this 4. Interpreter's Daytime Telephone Number form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immi 5. Interpreter's E-mail Address 3.a. Applicant's Signature 4 3.b. Date of Signature (mm/dd/yyyy) ► /Pt /2_012.6 ,Applicant's Contact InformatiO4 4. A icant's o Telephone Number 5. 4 obile Tele hone Number Fox=I-102 10/19/17 N Page 3 of 4 EFTA01699765 Part 5. Contact Information, Certification, and Pireparer's Contact Information Signature of the Interpreter(continued) 4. Preparer's Daytime Telephone Number Interpreter Certification I certify that: 5. Preparer's Fax Number I am fluent in English and ,which is the same language provided in Part 4., Item Number I.b.; 6. Preparer's E-mail Address I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number I.bz; and 7.a. g I am not an attorney or accredited representative but have prepared this form on behalf of the applicant The applicant has informed me that he or she understands every and with the applicant's consent. instruction and question on the form, as well as the answer to every question. 7.b. O I am an attorney or accredited representative and my representation of the applicant in this case 6.a. Interpreter's Signature (choose one) extends 0 does not extend O beyond the preparation of this form. 6.b. Date of Signature (mm/dd/yyyy) ► Voreparesnefroreson, By my signature, I certify, swear, or affirm, under penalty of Part ,66 Contact Information', litiatationvnadi perjury, that I prepared this form on behalf of at the request of, ISignaturnof ',the Person Preparing this and-with the express consent of the applicant. I completed the Application,,ItOther than the Applicant form based only on responses the applicant provided to me. „__. After completing the form, I reviewed it and all of the Preparer's PIO fh.7ame applicant's responses withthe applicant, who agreed with every _. answer provided for every question on the form and, when Provide the following information concerning the preparer: required, supplied additional information to respond to a question on the form. la. P r's Family Name, Last Naps) 8.a. 1.b. parefs GivenName (First Name) 8.b. 2. Preparers Business or Organization Name NOTE: If you need extra space to provide any additional fs information, attach a separate sheet of paper, type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and•Item Number to which 'Preparer's MailingAddress your answer refers; and date and sign each sheet. 3.a. Street Number and Name 2a FED6_12AL PLA2A 3.b. Apt. 0 Ste. FIr. 0 3.c. City or Town NEW yugi< 3.d. State N 3.e. ZIP Code I D2 78 3.f. Province 3.g. Postal Code 3.h. Country Li N ran smerec Form 1-102 10/19/17 N Page 4 of4 EFTA01699766 APPlinptitot For. EMployment Authorization TiRaS . Form T-7.65 Pepartineat-Of SOmetanctSecurity OMB Ho. 1615.0040 U.$: Citizenship andimmigratibn Services. Expires 05/31/2020 .. El Authorization/Extension teeStinlit Adtion block ValidTrom `For 0 Authorization/EXtention Valid:Through WSCISI Vat I 0 1'4 i Alien Registration Number A- I • z .. . s. . I Remarks • i .-•. To be completed byamattorne tor Seidelbeittsi,a(onitt; s2g Atteen4Yer Accredited Rel eotative Board of Immigration latittatbedi 1.1.S4S500#e-AcCOOlt-NI.#01, r (if any) acereditgdItte,p.Mseittneninif anY% 1. r•• 1 ► STARTElin - TtMe Orpri Riblitekink Tart 1.. Reason for Applying IfteriThat I am apnlyitiglor (selettotiVonamt): proVitle.all-etheragmles:yoh have ever used, including aliases, maiden name,.antInt6kintities. Ora neettram space to La. El. Initial•permIssionm accept employment tomplookshis section,, usothespace provided inPart 6. Lb, El Replacententollbstrstolen,nr dinnagedsmpkVineht AddItional•Ihforma authOrizatioitclootirnent,-Ortorreptiottof tiiy Name emplOyinentauthoriXatibwittictarieht•NOT:DOE to :(LitstNant6). U.S, OitizenShipandlintnigratiotiSertdcet(OSCIS) Given:Name . error. (4litst Igaine) NOTE: Replacement(correoti0:0 eat employment Xs. Middle Name. mithoristiOwdeconieftdue.tbAJSCIS err& &allot . . require a new IlbrarT,76$ anttili4fe6. Refer-to Xt. Fartilly:Naine RSplactinentlor CarannettrlinNiibirtsisthe (Last Maine) Filing7Fee section oltheEcirm146SinipitOtiona for lb. eineName further .(Firstblime) 1.e. ❑ Renewof-mypermissiorto acceptemployinent .MickileNlipe (Actiteirazt0pyptyouppreviotis.entployineitt authoriaatioadocemeet.) 4.a. Tamil Naipt: (1st Name) 4:0. Given:Ndme • .nfOtioilanaStilott$ TON (Firselslame). • 4.e. Middle Name La. Family Name (Lett Name) Lb. Given Name (Pint Name) Le. NfiddleName. Page 1 Ml Form I-765 Ot26/19 FUltalIMMEMEMPROMIIIII EFTA01699767 frt tf 2. ThroMnii0t1, Ybrt$OttnUfftilll I 134b. Provide your Sodiel.Secuti num N. Do you want-the SSA. to issueyon a Social:S.ecurity. card? (You4bnatelap answer "Yes" tolteanNtimber 15., 5.a. In Care Of Warne (if any) Consent for -DiselPsurt, to reteiVe.a. card.) 0 Yes No 5.b. Street Number and Name NOTE; If you answered "No" tmItetn.hintober 14., skip to.Fart7.., Item •b.lumbet18.a. Ifyou answered "Yes" to 5.c. 12 Apt 0 Ste. 0 Flr. ItemNumber 14., you mussaiso answer "Yes" to Item Nttifiber 15. 5.d. City or Town 15.. consent.forDiscloattre; LeuthorizecjiseloSure of infortiunioniftpintills:itifplicatibn tot/m.55A as required 5.e. State Ny ZIP Code for the purpose ofOsigriingintanS5Istand itsuingMe a SocialSeentitY Gerd 0Yes QNo 6. Is your current mailing addiesSliteaem asickUrplinical address? ?gliYes ONO NOTE: If you answered "Yet" to Hera Numbers N. -1$,,,providelhe information requested'tn Item NOTE: If94u. anaWererNO" totem-041111litre., Nutiffitta.164, -173), provideyourphySietliaddress-belom lather's.Nable - , Provide your fathere birlltnikne. 16.a. Tamilybianie trt. Street Numbs* (LasiName) andName 1633. Given Name 'Lb. In- Apt. LI'Ste. (FirstNatne) 7.c. City or Town MpthersName Provide:your mother's birth name. 7.d. State • 74. tffitodel 117.a. nuttily Name (Last Mole) areiretInterningffor 04h Given Name (First:Name) S. Alien Registration Nutriber(A-Num060(itiknyi . - ; * A- .1 ire&fpaunte MOOIrciiirepishOvr• 9. USCP.OnlineckeepulitNuMber(if.any). ptCyllOnglity P. -I. I : ; I I . alleOuntries wherey0trareturrentlyn citizen or national. Ifyottoeedtektevapacoto. complete this. item, use ibe space 10. Gender -(81 Female .pfitividoliivrairtk Mdikionallinform.ation. 11. MaritarStatus ('Single 0 Married. ;'Divorced 0WidOwed 10. Have you previbealy Sled ForitrI-765? 1133): _try °Yes ON° 13.a. Has theSociatSecurity Administration(SSA):ever officially issued a Social Security card to you? g Yes 0N° NOTE: If you.ansWered "No" Whim Number 13.a., skip to Rein Number 14. If you answered "Yes" to Item Number 13.24 provide thetfoimatiortrequeSteditiban Number13.1). Form 1-765 12126/19 Page 2 of 7 EFTA01699768 'Pant kfOrMatiott About VOu (tentanUed)/ njermation About YourEligibilittedtegory 27. Eligibility Category. Reflect° the Who May File -Form 1465 section of-the:Form-I-765 Instructions to determine the appropriate eligibility-category for this application. List the city/town/village, state/province, and country where Enter theiMproptiate letterand.nainber for your eligibility you were born. category:5Mb* (for-example, (a)(8), (WI (iii)). • 28. (e)(3)(C)STEM'OPT Eligibility Category: If you 19.b. State/Province of Binh entered the.oligibility category(e)(3)(C) in Item Number 27., provideithe information requestedinitemNtitithers 28.a - 28m. 19.0 Cou ofBirth 284.13egret 28ito. Bmploycesfitrim as Lisy4iwacyaify 20. Date ofairthOun/eldfioyy) 28.e. Employer's E-VeriftCbmpany Identification Nmilbet or a Aforn7alion:4tout Your LastArditallathr Valid E-Verity CliesinCOmpanyidentification Number UstitedStapif ;1.a. Form I-94.Arrival bepatinreatoordNumber (itany), .(eX26),Efigibilitytategory. If yon.entered-the eligibility category (426) in Itear-Ntnnber 2.t.,•pinvide the receipt number:ofyour 11-1ftspouse's most recent Petal I-797 2ub, Most RcoentlyzIsstred•Paasport Notiarfor FOtin I-129,Petition fora Nonimmigrant Worker. 21.e. Travel Document Number (if any): I 1 30. (e)(8)EligibilitrCategary. If yotraitered the.eligibility ixtE0yr.PasSpOrtorltaveliDocurnent category (oX8) inf tem Number 27., have you EVER 214. . • been arrested for and/or convicted ofany crime? OTh ❑ No 21.e. Expiration-bate for Passport Or NOTE: If you answered "Yes" to Item-Number 30., (iftre/ddlyyyy) refer to Spadini Tiling InstructiOntfor Thote With Fending:Asylum Applieationsfe)(8)inthe Required 22. DateolYotglastArtivallito.the-UnitedtnItes Ortor Becumentation section of the Form I-765 .instructions Abour(finti/dd/yra) for.information abontproviding court dispositions. 23. Place of tour Last Arrival Inter the.Unitt&States 31.a. (c)(35)and.(c)(36) Eligibility-Category. Ifyou entered cos . 644.;leterS critegoir(o)(35)1n•BentrNuMber 27.,.please provide•thc receipt:number of your Fortn I-797 Notice for 24. Immigration Status at Your Last Arrival. (for-example, Form 1440, Immigrant Petition for Alien Worker. If you 8-2Viaiter,1L1 student, or no status) enteredthe eligibility category (c)(36)in Item Number a 2/.,.please provide the receipt number-of your spouse's or parent's Form 1-797iNglitefOr FOnn1440, 25. YourCument Immigration-Status or Category4for. =ornate, ► B-2 visitor, F4 student, parolee, deferred.action, or no status or category) 31.b. If you entered the eligibility category (eX33) or (o)(36) in Item Nuntber27., have yowEVER been arrested for and/or convicted of any crime? UYes EiNo 26. Studentriad Exchange Visitor Information System (SEVIS)Number (if any) NOTE: If you answered "Yes" to Item Number 31.b., refer to Employment-Based Nonimmigrant Categories, Items I. - 9., in-theWho-May File Form I-765.section of the Fonn.I-76S Ihstmctions forinfomtatiowabout providing court dispositions. Form I-765 12/26/19 Page 3 of? EFTA01699769 art 3. Applicant's Statement, Contact Applicimt freelOratibitatifettliftattoit !Information, Declaration, Certificationvand! Copies of any documents•I have submitted are exact photocopies Signature of unaltered, originaIdocuments,:andlunderstand that USCIS May retttriro that I subrnitorigirialdocuments to USCIS at a later NOTE: Readthetenaltiessection.d.the Forin 1-766 date. Furthermore,.I authorize therelease of any inforthation Instructions before compledirgibi.s section. You mustae tabula* mid all.of my records thatUSCIS.may neetto Form I-765 while in the United States. detain:line my eligikility for the finmigration.beneflithat I seek. Appikanealatement Ifurther:mare authorize release ofinfonnation contained in this application, in supportingdocuments, and in my USCIS NOTE: Select the box for either Item Number 1.a. or 1.b. If records, to other entities and.persons where necessary for the applicable, select the box for Item Number 2. adminittration and enfottementof U.S. immigrationiew. 1.a. 1Z1 I can read and understand Engliak andthave read I understand that USCL5may require.me to appear for an And UnderstaricTeVery questionandinttibctiorfomthis appoint:tier:No take My'biomelties (fingerprints, photOgraph, application and my.answerte-every rmestion. zurdloreignature) and, at that time, if I am reel:fired to provide bioreetrice, rittridied tO.aign an oath reaffirming that Lb. ThoihterpreternaihedinFart.4..readtene question and instruction on this applicationkiidMy ItevieWtdandunderstoodzall•0f thejnformation tiMvyerM every question in contained in„and subthitted with, my appliCatiOn; and 2). 411-ofthis.inforrnation was complete, true,.and correct language in which Tam flaent, andI untletstriod at the time offiling. everything. liderlify, undet penalty. of.perjury, that all of the information in 2. A5 request; the prepaterzneumciligartr6.„,, My applitation and any dbeurn:Matairlmilitted•withit were providedof autholizedbymie, that reviewedand uliderataftel all.of the informati.5a4mitained in, and aubmitted With, my preparedthis application for tnegamed'Ohly. upon .application andthet alLof this infdrmation•is complete, true, and inforniaticin I provided& authorited. correct AppliontWtontad infoitmatiOn, 1 3. Applibruirs Daytime Telephone Numb 4. Applicant Mobile telephorieVziniberfipal; 7.b. Date of Signature (dtnidtVyys7) 03414 (tow ApplipanestmailMirot(itany) - NUTS Aix AOLICANTS: If you do.not completely fill 5. out.this:application or fiato submit requitadocuments listed in the Insituctions,USCIS rhay•climy your application. 6. El Select-thistoxif you area Salvadozan.or qualemaltut national' eligible for Benefits under the.Ape settlement agreement. lOart 4. IntetpreterteOntactinfOrinafttv .'Certification,andSigpature, • - Provide the-following information OM the interpreter. :fifiteVatkil, Frenfkinet la. Interpreter's, Family Name (Last Name) 1.b. Interpreter's GivenNamt(First Name) 2. Interpreteds Business or Organization Name Of any) Form 1-765 12126/19 III integri4zuparmiterake1m Page 4 of 7 EFTA01699770 Part 4. Interpreter's Contact In formatict4 !Part 5. Contact Inconunntion, Declaratialhad fertificatiOnrand Signature iSignat urelatthaPtitantitneparing this. Applicatinny Iffqater Tnaza the Applicant provide Oietellowiatinfoltualongoutine preparer. 3.a. Street Number and Name tweparertstfiterNamg, . . 3.b. El Apt 0 Ste. ❑ Fir. La. ilyNante (Laid Nana) 3.c. City or Town e (firstName) 3.d. State 3.e. ZIP Code 3.f. Proving!' 2. Vtepatee.;$usinet.s:ot, QTganitation Nnte:(if any). 3.g. Postal COS j 3.h. Country etira faMfg iling AftrY 4 and atftneam. ickiktPc 7'1 3a. aftpreteaseantaelintimmalk* . 3.11, El Apt. a Ste. larlik 4. literprptadspaytitno.lbIlliont Nigh* r : N • City.or town • • s ."‘14. 5. Interpretetl.biollile Telephone Mannegi so) Id. State lee Cade. 10.276 34. Ptoyince 6. Interpretedsmaii Addresrgapy), 3+ Postal Code Csingtex Otterpreteestroaallort N1' C5rikr-es I certify, uncler pentdty:of perjury, that • 044pgreKwdotNomoWit Lam-fluentda which is the.stheiniguagestiecificabibtiiitt3., iternaraii2bei 4. Pr aterfstpayOrhe Telephone Number . LfrandthaVe readto thit.appliCantin•theiidentitledlangbage every.cfuestiptrafteisti-uotierteit.this.applicatiee rindiii,corher answer to every question. Thcopplitpt ialinedmedaithe of 5. Preparees.Mobile Telepbene.Number (if any) she understanda every instruction, qt!.4tieilyenel,answei on-the application, inchMingthe Applicants VecliitAtionlind Oettifitation, and.has vetifietttheaccuntey °Eton lumen 6, • • • .fisP.meil.Address(iciarty). ninir;ter‘iiiitabir 1 7.a. Interpreter's $!gitattny 733. Date of Signature (mmiddiyyyy) Form I.765 12/26/19 Page 5 of 7 EFTA01699771 Part 5. Contact tniontnatiOn, beclaration, and' Signature citthe P,erson Preparing this Application, it Other Than the Applicant ,(continued 7.a. a lam not an attorney.or accredited representative but have prepared-this application on behalf of the applicant and with the applicant's Consent. 7.b. oI am an attorney or accredited representative and my represehtati0n &the applicantrin thireale El❑extends bdoct noteidendttypit4lbct. preparation of thisapplicaliOn. NOTEF Ityotriettiztiltorit*yOtAcctetlited rdpittentativet ply,thay: needle subillt a cornpletedTont.04kbrotico.oftritay of AppearancesitrAttonaepds k.constlitett Representative, withrthisapplidatitut. IPtejkotift ea/Pal/oft Efy my signature,!certify; under penalty of perjury; thatl prepared this Opilicatibrpatthe request of the applicants The applicanttlien itviessiediffittornpittotapnlication.anct informedMothatbe.or She understanda all of theinfonhation. contained in, anrksulanitte&With„hia.ok heiapplication, including the Applicant's DrAiriitiOn IittLeertification, and that allof this infoimationis coifipItte, true, and.coftct. completed'thiSapplicatiowbased only owinfennatioWthasthe applibtutt prosidetholneorauthosizettmetwObtaiworust Oieepitterct,Pknalure kb. Date of Signature (nt yyyy) Formai-765 12/26/19 IIII faliiMICRWMPAWEIMMIIIII Page 6 of 7 EFTA01699772 Part4. Additional Information 5.a. Page Number 5.b. IPartNumber, Le. Item Number If you need extra space to provide any additional information I. within this application, use the space below. If you. heed'inote space than what is provided, yob may inake.copie4 of this page to complete and fde with this application. Or.attach &separate. sheet of paper. Type or print your name and Asblumber(if any.) at the top of each sheet; indicate the PageNuniber, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Family Name (Last Neale) 1.b. Given Name (First Naine) 1.c. Middle Name 6.a. 11.'40:Number 64 Partlumfler 6.c. Item Number 2. A-Number (itanA. * A 1 i - I . 31a. PageNunther 3,1f. 1WtNtintber 3i,e, I 34. 74. Page-Number 4.b, Part blumber 4A Item:Number 4.d. Page 7 of 7 Form I-765 12/26/19 RONIMEMOIStiftifttliSMUMIIIII EFTA01699773 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. 'Fel: I -800-262-DCJS Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CBS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is pros ided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Female Race: Unknown Date of Birth: NYFBINYC 0 NO NCIC WANT RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Federal NCIC WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CRS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Female Race: Unknown Date of Birth: EFTA01699774 NYFBINY 0 0 NO NCIC PROTECTION ORDER FILE RECORD RAC/U SEX/F Additional Inquiry Response ORI: NYRBINV00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel- Michael C.Grccn, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *III Information * The following information is provided in response to your request fora search of the III based on: Name: Sex: Female Race: Unknown Date of Birth: Purpose Code: NYFBINY00 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM DOB/ .SEX/F.RAC/U.PUR/C.ATN/MEDERR. END EFTA01699775 Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJ IS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC restricted and non-restricted files. The following information is provided in response to your request for a search of the NCIC - Person Files based on: Name: Sex: Female Race: Unknown Date of Birth: NYFBINY00 NO NCIC WANT NAM/ DOB RAC/U SEX/F ***MESSAGE KEY QWA SEARCHES ALL NCIC PERSONS FILES WITHOUT LIMITATIONS. Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St. Albany, New York 12210. Tel. Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services *Federal NCIC * WARNING: Release of any NCIC information to unauthorized individuals or agencies,including the subject of the data, is prohibited. Please refer to section 4.2 of the CJ IS security policy and Title 28, Part 20 of the code of Federal Regulations for the proper acess, use, and dissemination of the information contained in the NCIC EFTA01699776 restricted and nonrestricted The following information is provided in response to your request for a search of the NCIC - Protection Order File based on: Name: Sex: Female Race: Unknown Date of Birth: NYFBINY0 D NO NCIC PROTECTION ORDER FILE RECORD NAM/ DOB/ RAC/U SEX/F Additional Inquiry Response ORI: NYFBINY00 Federal Bureau of Investigation - New York New York State Division of Criminal Justice Services Alfred E. Smith Building, 80 South Swan St Albany, New York 12210. Tel Michael C.Green, Executive Deputy Commissioner of the NYS Division of Criminal Justice Services ti III Information * The following information is provided in response to your request for a search of the III based on: Name: Sex: Female Race: Unknown Date of Birth: Purpose Code: NYFRTNY00 NO IDENTIFIABLE RECORD IN THE NCIC INTERSTATE IDENTIFICATION INDEX (III) FOR NAM/I DOB/ .SEX/F.RAC/U.PUR/C.ATN/MEDERK. END EFTA01699777 DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE Part A: Information on the Victim 1. Name: (Last) (First) (Middle) 2. Date of Birth (mo., day, yr.) 3. Country of Birth 4. Country of Citizenship 5. Alias(es) 6. Gender (check one) 7. Alien Number (A#) ❑ Male ❑ Female A 8. Passport Number 9. Country of Issuance 10. Expiration Date (mo., day, yr.) 11. Social Security Number Part B: Requesting Agency Information •Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: 2. Daytime telephone number 3. Fax number (First, Last) (include area code) Ext 2. Case Agent where the Victim resides (if the Victim resides in a jurisdiction other than that of the Lead Case Agent): (First, Last) 2. Daytime telephone number 3. Fax number (include area code) Ext. Supplemental Information: Requesting Agency: Group Supervisors name (First, Last) ext. Daytime telephone number (including area code) Fax number Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA01699778 Victim-Witness Specialist's/Coordinator's name (First, Last) Daytime telephone number (including area code) ext. Fax number Part C: Case Information Wote: Please complete all information below. 1. Is the Victim currently in the United 0 Yes 0 No States? 2. The Victim's current immigration status: 3. Is the Victim requesting Continued Presence based upon a pending civil action under 18 U.S.C. § 1595? CI Yes 0 No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? 0 Yes glio (if yes, where and when) City, State: 5. When did the Victim enter the United States? 6. Through which Port of Entry did the Victim enter the United States? 7. How did the Victim enter the United States? nr Part D: Specific Information Pertaining to the Victim * Please answer each question as completely as possible (Attach additional sheet(s), if necessary.) 1. Significance and value of the Victim to this case: (Please provide a brief explanation of how the Victim meets the definition of "severe form of trafficking' under section 103(8), Victims of Trafficking and Violence Protection Act of 2000, Pub. L. No. 106-386.) 2. The Victim's criminal Involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) 3. Risk the Victim presents to public safety and/or to national security (i.e., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary; (Attach copy of risk assessment report) 4. Financial responsibility for the Victim: (Please explain manner in which the Victim's living expenses will be met) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA01699779 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state; attach additional sheet(s), if necessary.) 6. Is employment authorization requested? ❑ Yes ❑ No (If yes, please attach completed U.S. Citizenship and Immigration Services Forms 1-765, Application for Employment Authorization, and 1-102, Application for Replacement/Initial Nonimmigrant Arrival/Departure Document.) Note: Information contained in question # 7 is not required for a victim to receive Continued Presence; however, this information is required for a victim to be certified to receive benefits from the Department of Health and Human Services (HHS), Office of Refugee Resettlement (ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. Is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. ✓Yes ❑ No Part E: Location where the Victim will reside (City and state are required at a minimum.) Street Address City State *Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for Continued Presence must be submitted to the ICE HSI Headquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reported to the requesting agency headquarters, which in turn will notify LEPU. The requesting agency will also notify LEPU immediately if the alien departs the United States. Part F: Certification of Reporting Requirements As the requesting agency representative, I understand that, should this Continued Presence be granted, it is MY responsibility to follow all of the policies and procedures established by LEPU, including quarterly reporting, reporting changes in the Victim's status (i.e., departure or change in status), and requesting applicable extensions 30 days prior to the expiration of approved Continued Presence. (Lead Group Supervisor's Signature) (Date) (Print Name and Title) (Lead Case Agent's Signature) (Date) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) f3age 3 of 4 EFTA01699780 If the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Date) (Print Name and Tide) (Monitoring Case Agent's Signature) (Date) (Print Name and Title) Privacy Act Statement Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form will be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting law enforcement officer/agent and their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, intemational or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted under 5 U.S.C. § 552a(b) pursuant to the routine uses published in the Department of Homeland Security system of records notice, DHS/ICE-011 Immigration and Enforcement Operational Records. Disclosure: The disclosure of the information on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of the request for Continued Presence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 4 of 4 EFTA01699781 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document USCIS Form 1-102 Department of Homeland Security OMB No. 1615-0079 U.S. Citizenship and Immigration Services Expires 10/31/2019 Receipt Action Block To Be Completed by an Attorney or Accredited Representative, if any. For O Select this box if Form USCIS O-28 is attached to Use New 1-94 Number represent the applicant Only Attorney State License Number Remarks 0.• START HERE. Type or print in black ink Part 1. Information About You U.S. Physical Address 1. Alien Registration Number (A-Number) 6.a. In Care Of Name la• A- 2. USCIS Online Account Number (if any) 6.b. Street Number and Name MPH 6.c. Apt. O Ste. O Flr. O Your Full Name 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6.1. ZIP Code 3.b. Given Name (First Name) Other Information 3.c. Middle Name 7. Date of Birth (nmildcliyyyy) 10. U.S. Mailing Address 8. un of Birth 4.a. In Care Of Name 9. Coun of Citizenshi 4.b. Street Number and Name 10. U.S. Social Security Number if an 4.c. Apt p Ste. 4.d. City or Town Weilm gory. Entry Information 4.e. State 4.f. ZIP Code 100(.95 11. Date of Last Entry into the United States 5. Is your current U.S. mailing address the same as your (mni/dellyyyy) ► U.S. physical address? ErYes 0 No oi/a/e301° If you answered No" to Rem Number 5., provide your 12. Place of Last Entry into the United States (City and State) U.S. physical address in Item Numbers 6.a. - 6.f. Los Ankles ) CA Form 1-102 10/19/17 N Page 1 of 4 EFTA01699782 Part 1. Information About You (continued) Part 3. Processing Information 13. Current Nonimmigrant Status 1.a. Are you filing this application with any other petition or application? Visa O Yes No 14. Date Status Expires If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number 1.b. (mnt/dd/yyyy)10. oa/ast i 15.a. Form I-94,1-94W, or I-95 Arrival-Departure Record Number 1.b. USCIS Form Number and Name 2.a. Are you now in removal proceedings? O Yes 'No 15.b. Passport Number If "Yes" complete Item Number 2.b. 15.e. Travel Document Number J 2.b. Provide detailed information regarding the proceedings. 15.d. Coun of Issuance for Passport or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; 15.e. Expiration Date for Passport or Travel Document indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign (mm/dd/yyyy) ► 08* qboo each sheet. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) 1.a. O I am applying to replace my lost or stolen Form 1-94 or I-94W. 1.b. ID I am applying to replace my lost or stolen Form 1-95. 1.c. O I am applying to replace my Form 1-94 or I-94W because it was mutilated. I have attached my original Form 1-94 or I-94W. 1.d. O I am applying to replace my Form I-95 because it was If you are unable to provide the original of your Form 1-94, mutilated. I have attached my original Form 1-95. I -94W, or 1-95, provide the following information: 1.e. [Punts not issued Form I-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form 1-94, CBP at a port-of-entry in the United States (whether I-94W, or I-95. at a landborder, airport, or seaport). 3.a. Family Name 1.f. ❑ I was issued Form I-94, I-94W, or I-95 with incorrect (Last Name) information, and I am requesting that USCIS correct the 3.b. Given Name document I have attached my original Form 1-94, (First Name) I-94W, or1-95. 3.c. Middle Name 1.g. O I was not issued Form 1-94 when I entered as a 4. Class of Admission at Last Entry into the United States nonimmigrant member of the military, and I am filing this application for an initial Form 1-94. tevne,Weol Passport 5. Place of Last Entry into the United States (City and State) Lees -Amities 1 OA Form 1-102 10/19/17 N Page 2 of4 EFTA01699783 Part 5. Contact Information, Certification, and Preparer's Contact Information Signature of the Interpreter (continued) 4. Preparer's Daytime Telephone Number Interpreter Certification I certify that: S. Preparer's Fax Number I am fluent in English and ,which is the same language provided in Part 4., Item Number Lb.; 6. Preparers E-mail Address I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number 1.13.; and 7.a. ❑ I ant not an attorney or accredited representative but have prepared this form on behalf of the applicant The applicant has informed me that he or she understands every and with the applicant's consent. instruction and question on the form, as well as the answer to every question. 7.b. ❑ I am an attorney or accredited representative and my representation of the applicant in this case 6.a. Interpreter's Signature (choose one) extends ❑ does not extend ❑ beyond the preparation of this form. 6.b. Date of Signature (rimildd/yyyy) ► Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of Part 6. Contact Information, Declaration, and perjury, that I prepared this form on behalf of, at the request of, Signature of the Person Preparing this and with the express consent of the applicant. I completed the Application, If Other than the Applicant form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the Preparer's Full Name applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when Provide the following information concerning the preparer: required, supplied additional information to respond to a question on the form. 1.a. Preparers Family Name (Last Name) 8.a. Prepares Signature Lb. Prepares Given Name (First Name) 8.b. Date of Signature (rmn./dd/yyyy) ► 2. Prepares Business or Organization Name NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper, type or print your name and A-Number (if any) at the top of each sheet; indicate Preparer's Mailing Address the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. 3.a. Street Number and Name 3.b. Apt. ❑ Ste. ❑ Flr. ❑ 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Form 1-102 10/19/17 N Page 4 of 4 EFTA01699784 Part 4. Statement, Certification, Signature, and Part 5. Contact Information, Certification, and Contact Information of the Applicant Signature of the Interpreter NOTE: Select the box for either Item Number l.a. or Lb. If Interpreter's Full Name applicable, select the box for Item Number 2. l.a. ❑ I can read and understand English, and have read and Provide the following information concerning the interpreter: understand every question and instruction on this l.a. Interpreter's Family Name (Last Name) form, as well as my answer to every question. 1 1.b. O The interpreter named below has read to me every question and instruction on this form, as well as my 1.b. Interpreter's Given Name (First Name) answer to every question, in 2. Interpreter's Business or Organization Name (if any) a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated Interpreter's Mailing Address above. 3.a. Sheet Number 2. ❑ I have requested the services of and consented to and Name 3.b. Apt. ❑ Ste. ❑ Fir. ❑ who is ❑ is not ❑ an attorney or accredited 3.c. City or Town representative, preparing this form for me. 3.d. State 3.e. ZIP Code Applicant Certification 3.f. Province I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact 3.g. Postal Code photocopies of unaltered original documents, and I understand that I may be required to submit original 3.h. Country documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I Interpreter's Contact Information furthermore authorize release of information contained in this 4. Interpreter's Daytime Telephone Number form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration ofU.S. immigration laws. 5. Interpreter's E-mail Address 3.a. Applicant's Signature S 3.b. Date of Signature (mm/dd/yyyy) ► Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Form I-102 10/19/t7 N Page 3 of EFTA01699785 Application For Employment Authorization USCIS Form I-765 Department of Homeland Security OMB No. 1615.0040 U.S. Citizenship and Immigration Services Expires 05/31/2020 Authorization/Extension Fee Stamp Action Block Valid From For Authorization/Extension Valid Through USCIS Use Only Alien Registration Number A- I I I Remarks To be completed by an attorney or Select this box if Form G-28 Attorney or Accredited Representative Board of Immigration Appeals (13IA)- is attached. USCIS Online Account Number (if any) accredited representative (if any). ► START HERE - Type or print in black ink Part 1. Reason for Applying Other Names Used I am applying for (select only one box): Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to l.a. O Initial permission to accept employment. complete this section, use the space provided in Part 6. I.b. D Replacement of lost, stolen, or damaged employment Additional Informer authorization document, or correction of my 2.a. Family Name employment authorization document NOT DUE to (Last Name) U.S. Citizenship and Immigration Services (USCIS) 2.b. Given Name error. (First Name) NOTE: Replacement (correction) of an employment 2.c. Middle Name authorization document due to USCIS error does not require a new Form 1-765 and filing fee. Refer to 3.a. Family Name Replacement for Card Error in the What is the (Last Name) Filing Fee section of the Form 1-765 Instructions for 3.b. Given Name further details. (First Name) 1.c. Renewal of my permission to accept employment. 3.c. Middle Name (Attach a copy of your previous employment authorization document.) 4.a. Family Name (Last Name) Part 2. Information About You 4.b. Given Name (First Name) 4.c. Middle Name Your Full Legal Name I.e. Family Name (Last Name) I.b. Given Name (First Name) 1.c. Middle Name Form 1-765 12/26/19 Page 1 of 7 'III EFTA01699786 Part 2. Information About You (continued) 13.b. Provide your Social Secu PO' Your U.S. Mailing Address 14. Do you want the SSA to issue you a Social Security card? (You must also answer "Yes" to Item Number 15., 5.a. Consent for Disclosure, to receive a card.) 0 Yes 0 No 5.b. Street Number and Name NOTE: If you answered "No" to Item Number 14., skip to Part 2., Item Number 18.a. If you answered "Yes" to 5.e. Apt. ❑ Ste. ❑ Flr. Item Number 14., you must also answer "Yes" to Item Number 15. 5.d. City or Town Naze) uor- 15. Consent for Disclosure: I authorize disclosure of 5.e. State 5.f. ZIP Code information from this application to the SSA as required I 00105 for the purpose of assigning me an SSN and issuing me a Social Security card. ❑ Yes ❑ No 6. Is your current mailing address the same as your physical address? []'Yes 0 No NOTE: If you answered "Yes" to Item Numbers 14. - 15., provide the information requested in Item NOTE: If you answered "No" to Item Number 6., Numbers 16.a. - 17.b. provide your physical address below. Father's Name U.S. Physical Address Provide your father's birth name. 16.a. Family Name 7.a. Street Number (Last Name) and Name 16.b. Given Name 7.b. ❑ Apt. ❑ Ste. ❑ Flr. (First Name) 7.c. City or Town Mother's Name Provide your mother's birth name. 7.d. State 7.e. ZIP Code 17.a. Family Name (Last Name) Other Information 17.b. Given Name (First Name) 8. Alien Registration Number (A-Number) (if any) ► A- Your Country or Countries of Citizenship or 9. USCIS Online Account Number (if any) Nationality List all countries where you are currently a citizen or national. If you need extra space to complete this item, use the space 10. Gender ❑ Male [✓Female provided in Part 6. Additional Information. 11. Marital Status 18.a. Coun Eraingle ❑ Married ❑ Divorced ❑ Widowed 12. Have you previously filed Form I-765? 18.b. Country ❑Yes E'No 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ErYes ❑ No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you answered "Yes" to Item Number 13.a., provide the information requested in Item Number 13.b. Page 2 of 7 Form 1-765 12/26/19 ItIMPINSPONEWS=MallIIII EFTA01699787 I Part 2. Information About You (continued) Information About Your Eligibility Category 27. Eligibility Category. Refer to the Who May File Form Place of Birth I-765 section of the Form I-765 Instructions to determine the appropriate eligibility category for this application. List the city/town/village, state/province, and country where Enter the appropriate letter and number for your eligibility you were born. category below (for example, (aX8), (cX17)(iii)). 19.a. CityfrownNillage of Birth (Mu 28. (c)(3)(C) STEM OPT Eligibility Category. If you 19.b. State/Province of Birth entered the eligibility category (cX3XC) in Item Number 27., provide the information requested in Item Numbers 28.a - 28.c. 19.c. Country of Birth 28.a. Degree 28.b. Employer's Name as Listed in E-Verify 20. Date of Birth (mm/dcVyyyy) 28.c. Employer's E-Verify Company Identification Number or a Information About Your Last Arrival in the Valid E-Verify Client Company Identification Number United States 21.a. Form I-94 Arrival Departure Record Number (if any) 29. (c)(26) Eligibility Category. If you entered the eligibility Ito category (cX26) in Item Number 27., provide the receipt number of your H-1B spouse's most recent Form 1-797 21.b. Passport Number of Your Most Recently Issued Passport Notice for Form 1-129, Petition for a Nonimmigrant Worker. 21.e. Travel Document Number (if any) ► 30. (c)(8) Eligibility Category. If you entered the eligibility category (c)(8)in Item Number 27., have you EVER 21.d. Country That Issued Your Passport or Travel Document been arrested for and/or convicted of any crime? El Yes ONo 21.e. Expiration Date for Passport or Travel Document NOTE: If you answered "Yes" to Item Number 30., (mm/dd/yyyy) refer to Special Filing Instructions for Those With Pending Asylum Applications (cX8) in the Required 22. Date of Your Last Arrival Into the United States, On or Documentation section of the Form I-765 Instructions About (mm/dd/yyyy) for information about providing court dispositions. 23. Place of Your Last Arrival Into the United States 31.a. (O(35) and (cX36) Eligibility Category. If you entered the eligibility category (c)(35) in Item Number 27., please provide the receipt number of your Form 1-797 Notice for 24. Immigration Status at Your Last Arrival (for example, Form I-140, Immigrant Petition for Alien Worker. If you B-2 visitor, F-I student, or no status) entered the eligibility category (eX36) in Item Number 27., please provide the receipt number of your spouse's or 1 parent's Form I-797 Notice for Form 1-140. 25. Your Current Immigration Status or Category (for example, B-2 visitor, F-I student, parolee, deferred action, or no status or category) 31.b. If you entered the eligibility category (cX35) or (cX36) in Item Number 27., have you EVER been arrested for and/or convicted of any crime? ❑Yes ❑ No 26. Student and Exchange Visitor Information System (SEWS) Number (if any) NOTE: If you answered "Yes" to Item Number 31.b., ► N- refer to Employment-Based Nonimmigrant Categories, Items 8. - 9., in the Who May File Form I-765 section of the Form I-765 Instructions for information about providing court dispositions. Page 3 of 7 Form I-765 12/26/19 VgartIPSIsitigNittrttliginling011111 EFTA01699788 Part 3. Applicant's Statement, Contact Applicant's Declaration and Certification Information, Declaration, Certification, and Copies of any documents I have submitted are exact photocopies Signature of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later NOTE: Read the Penalties section of the Form I-765 date. Furthermore, I authorize the release of any information nstructions before completing this section. You must file from any and all ofmy records that USCIS may need to Form I-765 while in the United States. determine my eligibility for the immigration benefit that I seek. Applicant's Statement I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS NOTE: Select the box for either Item Number l.a. or 1.b. If records, to other entities and persons where necessary for the applicable, select the box for Item Number 2. administration and enforcement ofU.S. immigration law. 1.a. Olean read and understand English, and I have read I understand that USCIS may require me to appear for an and understand every question and instruction on this appointment to take my biometrics (fingerprints, photograph, application and my answer to every question. and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1.b. El The interpreter named in Part 4. read to me every question and instruction on this application and my 1) I reviewed and understood all of the information answer to every question in contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct a language in which I am fluent, and I understood at the time of filing. everything. I certify, under penalty of perjury, that all of the information in 2. El At my request, the preparer named in Part 5., my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my prepared this application for me based only upon application and that all of this information is complete, true, and information I provided or authorized. correct. Applicant's Contact Information Applicant's Signature 3. Applicant's Daytime Telephone Number 7.a. Applicant's Signature 4 4. Applicant's Mobile Telephone Number (if any) 7.b. Date of Signature (nunAld/yyyy) NOTE TO ALL APPLICANTS: if you do not completely fill 5. Applicant's Email Address (if any) out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. 6. El Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC Part 4. Interpreter's Contact Information, settlement agreement. Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name l.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Form 1.765 12/26/19 Page 4 of7 Ill Walgialealrefiktffittailfeiallfill EFTA01699789 Part 4. Interpreter's Contact Information, Part 5. Contact Information, Declaration, and Certification, and Signature Signature of the Person Preparing this Application, If Other Than the Applicant Interpreter's Mailing Address Provide the following information about the preparer. 3.a. Street Number and Name Preparer's Full Name 3.b. ❑ Apt. ❑ Ste. ❑ Flr. 1.a. Preparer's Family Name (Last Name) 3.c. City or Town 1.b. Preparer's Given Name (First Name) 3.d. State 3.e. ZIP Code 3.f. Province 2. Preparer's Business or Organization Name (if any) 3.g. Postal Code 3.h. Country Preparer's Mailing Address 3.a. Street Number and Name Interpreter's Contact Information 3.b. ❑ Apt. ❑ Ste. ❑ Flr. 4. Interpreter's Daytime Telephone Number 3.c. City or Town 5. Interpreter's Mobile Telephone Number (if any) 3.d. State 3.e. ZIP Code 3.f. Province 6. Interpreter's Email Address (if any) 3.g. Postal Code 3.h. Country Interpreter's Certification I certify, under penalty of perjury, that: Preparer's Contact Information I am fluent in English and which is the same language specified in Part 3., Item Number 4. Preparer's Daytime Telephone Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or 5. Preparer's Mobile Telephone Number (if any) she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy ofevery answer. 6. Preparer's Email Address (if any) Interpreter's Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mmiddiyyyy) Page 5 of 7 Form 1-765 12/26/19 Cpl IMERIAMPaiffnicallPI EFTA01699790 Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant (continued) Preparer's Statement 7.a. ❑ I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent 7.b. El I am an attorney or accredited representative and my representation of the applicant in this case 0 extends El does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice ofEntry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8.a. Preparer's Signature 8.b. Date of Signature (mmidd/yyyy) Page 6 of 7 Form 1-765 12/26/19 11111 FUMMIPPOStitt6IMINDTATIMIIIIII EFTA01699791 Part 6. Additional Information 5.a. Pa e Number 5.b. Part Number 5.c. Item Number If you need extra space to provide any additional information within this application, use the space below. If you need more 5.d. space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) l.c. Middle Name 6.a. Pa e Number 6.b. Part Number 6.e. Item Number 2. A-Number or any) lo A- 6.d. 3.2. Pa e Number 3.b. Part Number 3.c. Item Number 3.d. 7.a. Pas_ e 7 Number 7.b. Part Number 7.c. Item Number 7.d. 4.a. Pa Number 4.b. Part Number 4.c. Item Number 4.d. Forrn 1-765 12/26/19 El morommargentwommt Page 7 of 7 EFTA01699792 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document USCIS Form I-102 Department of Homeland Security OMB No. 1615-0079 U.S. Citizenship and Immigration Services Expires 10/31/2017 Receipt Action Block To Be Completed by an Attorney or Accredited Representative, if any. For ❑ Select this box ifForm USCIS G-28 is attached to Use New 1-94 Number represent the applicant Only Attorney State License Number Remarks ► START HERE. Type or print in black ink Part 1. Information About You U.S. Physical Address 1. Alien Registration Number (A-Number) 6.a. In Care Of Name ► A- I I I 2. USCIS Online Account Number (if any) 6.b. Street Number and Name I I I i 6.c. Apt ❑ Ste. ❑ FIr. ❑ Your Full Name 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6.f. ZIP Code 3.b. Given Name (First Name) Other Information 3.c. Middle Name 7. Date of Birth (mm/dd/yyyy) ► U.S. Mailing Address 8. Country ofBirth 4.a. In Care OfName 9. Country of Citizenship 4.b. Street Number and Name 10. U.S. Social Security Number (ifany) 4.c. Apt. ❑ Ste. ❑ FIr. ❑ 4.d. City or Town Entry Information 4.e. State 4.f. ZIP Code 11. Date ofLast Entry into the United States 5. Is your current U.S. mailing address the same as your (mmirld/3557) ► U.S. physical address? ❑ Yes fl No If you answered "No" to Item Number 5., provide your 12. Place ofLast Entry into the United States (City and State) U.S. physical address in Item Numbers 6.a. - 6.f. Portal-102 12/23/16 N Page I of4 EFTA01699793 Part 1. Information About You (continued) l iart 3. Processing Information 13. Current Nonimmigrant Status 1.a. Are you filing this application with any other petition or application? 0 Yes 0 No 14. Date Status Expires If "Yes" provide the USCIS Form Number and name of the ( 11mAid/Y)731) ► application or petition you are filing in Item Number 1.b. 15.a. Form I-94,1-94W, or I-95 Arrival-Departure Record Number USCIS Form Number and Name I I /a. Are you now in removal proceedings? 0 Yes 0 No 15.b. Passport Number If Wes" complete Item Number 2.b. 15.e. Travel Document Number 2.b. Provide detailed information regarding the proceedings. 15.d. County of Issuance for Passport or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; 15.e. Expiration Date for Passport or Travel Document indicate the Page Number, Part Number, and Item (mm/dd/yyyy) ► Number to which your answer refers; and date and sign each sheet. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) 1.a. 0 I am applying to replace my lost or stolen Form I-94 or I-94W. 1.b. O I am applying to replace my lost or stolen Form I-95. 1.e. O I am applying to replace my Form I-94 or I-94W because it was mutilated. I have attached my original Form I-94 or I-94W. 14. El I am applying to replace my Form I-95 because it was If you are unable to provide the original of your Form I-94, mutilated. I have attached my original Form I-95. I -94W, or I-95, provide the following information: 1.e. O I was not issued Form I-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form 1-94, CBP at a port-of-entry in the United States (whether I -94W, or I-95. at a land border, airport, or seaport). 3.a. Family Name IS. 0 I was issued Form I-94,1-94W, or I-95 with incorrect (Last Name) information, and I am requesting that USCIS correct the 3.b. Given Name document. I have attached my original Form I-94, (First Name) I-94W, or I-95. 3.c. Middle Name 1.g. O I was not issued Form I.94 when I entered as a 4. Class of Admission at Last Entry into the United States nonimmigrant member of the military, and I am filing this application for an initial Form I-94. 5. Place of Last Entry into the United States (City and State) Form I-102 12/23/16 N Page 2 of 4 EFTA01699794 Part 4. Statement, Certification, Signature, and Part 5. Contact Information, Certification, and Contact Information of the Applicant Signature of the Interpreter NOTE: Select the box for either Item Number 1.a. or Lb. If Interpreter's Full Name applicable, select the box for Item Number 2. Provide the following information concerning the interpreter: La. O I can read and understand English, and have read and understand every question and instruction on this I.a. Interpreter's Family Name (Last Name) form, as well as my answer to every question. 1.b. O The interpreter named below has read to me every question and instruction on this form, as well as my Lb. Interpreters Given Name (First Name) answer to every question, in 2. Interpreters Business or Organization Name (if any) a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated Interpreter's Mailing Address above. 3.a. Street Number 2. O I have requested the services of and consented to and Name 3.b. Apt. O Ste. 0 FIr. who is 0 is not 0 an attorney or accredited 3.c. City or Town representative, preparing this form for me. 3.d. State 3.e. ZIP Code Applicant Certification 3.f. Province I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact 3.g. Postal Code photocopies of unaltered original documents, and I understand that I may be required to submit original 3.h. Country documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I Interpreter's Contact Information furthermore authorize release of information contained in this 4. Interpreter's Daytime Telephone Number form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws. 5. Interpreter's E-mail Address 3.a. Applicant's Signature 4 3.b. Date of Signature (mmicld/yyyy) ► Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Form 1-102 12123/16 N Page 3 of 4 EFTA01699795 Part 5. Contact Information, Certification, and Preparer's Contact Information Signature of the Interpreter (continued) 4. Preparer's Daytime Telephone Number Interpreter Certification I certify that: 5. Preparer's Fax Number I am fluent in English and ,which is the same language provided in Part 4., Item Number 1.b.; 6. Preparer's E-mail Address I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., item Number 1.b.; and 7.a. ❑ I am not an attorney or accredited representative but have prepared this form on behalf of the applicant The applicant has informed me that he or she understands every and with the applicant's consent instruction and question on the form, as well as the answer to every question. 7.b. ❑ lam an attorney or accredited representative and my representation of the applicant in this case 6.a. Interpreter's Signature (choose one) extends ❑ does not extend ❑ beyond the preparation of this form. 6.b. Date of Signature (rninidd/yyyy) ► Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of Part 6. Contact Information, Declaration, and perjury, that I prepared this form on behalf of, at the request of, Signature of the Person Preparing this and with the express consent of the applicant. I completed the Application, If Other than the Applicant form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the Preparer's Full Name applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when Provide the following information concerning the preparer: required, supplied additional information to respond to a question on the form. 1.a. Preparer's Family Name (Last Name) &a. Preparer's Signature 1.b. Preparer's Given Name (First Name) &b. Date of Signature (mm/dd/yyyy) ► 2. Preparers Business or Organization Name NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet; indicate Preparer's Mailing Address the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. 3.a. Street Number and Name 3.b. Apt ❑ Ste. ❑ Flr. 3.c City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 31. Country Form I-102 12/23/16 N Page 4 of 4 EFTA01699796 Application For Employment Authorization USCIS Form 1-765 Department of Homeland Security OMB No. 1615-0040 U.S. Citizenship and Immigration Services Expires 02/28/2018 Fee Stamp Action Block Initial Receipt Resubmitted For USCIS Relocated Use Received Sent Only Completed ❑ Application Approved O Application Denied - Failed to establish: Approved Denied ❑ Au horization/Extension Valid From O Eligibility under O Economic necessity under 8 CFR 274a.12 8 CFR 274a:12(0O4)v (18) O Autbotization/Extevsko Valid To (a) or (e) and S CFR 214.20) AN Subject to the tollo"ing conditions: ❑ Applicant Is tiling under section 274a.12 ► START HERE - Type or print in black ink. I am applying for 9. Social Security Number (Include all numbers you have ever used, if any) ❑ Permission to accept employment. ❑ Replacement (of lost employment authorization document). 10. Alien Registration Number (A-Number) or Form 1-94 ❑ Renewal of my permission to accept employment (attach a Number (if any) copy of your previous employment authorization document). 1. Full Name 11. Have you ever before applied for employment authorization from USCIS? Family Name First Name Middle Name ❑ Yes (Complete the following questions.) Which USCIS Office? Dates 2. Other Names Used (include Maiden Name) Family Name First Name Middle Name Results (Granted or Denied - attach all documentation) ❑ No (Proceed to Question 12.) 3. U.S. Mailing Address 12. Date of Last Entry into the U.S., on or about Street Number and Name Apt. Number (mm/dd/yyyy) Town or City State ZIP Code 13. Place of Last Entry into the U.S. 4. Country of Citizenship or Nationality 14. Status at Last Entry (B-2 Visitor, F-1 Student, No Lawful Status, etc.) 5. Place of Birth Town or City State/Province Country 15. Current Immigration Status (Visitor, Student, etc.) 6. Date of Birth (nun/dcl/yyyy) 16. Eligibility Category. Go to the "Who May File Form I-765?" section of the Instructions. In the space below, place 7. Gender ❑ Male ❑ Female the letter and number of the eligibility ca egory you selected 8. Marital Status ❑ Single ❑ Married ❑ Divorced ❑ Widowed from the instmctions. For example, (a)(8), (c)(17)(iii), etc. ( )(I'M ) Form 1-765 01/17/17 N Page 1 of 2 EFTA01699797 17. (c)(3)(C) Eligibility Category. If you entered the Certification eligibility category (c)(3)(C) in Question 16 above, list your degree, your employees name as listed in E-Vcrify, I certify, under penalty of perjury, that the foregoing is true and and your employer's E-Verify Company Identification correct. Furthermore, I authorize the release of any information Number or a valid E-Verify Client Company Identification that U.S. Citizenship and Immigration Services needs to Number in the space below. determine eligibility for the benefit I am seeking. I have read the "Who May File Form I-765?" section of the instructions Degree Employer's Name as listed in E-Verify and have identified the appropriate eligibility category in Question 16. Applicant's Signature Employer's E-Verify Company Identification Number or a Valid E-Verify Client Company Identification Number Date of Signature (mm/dd/yyyy) 18. (c)(26) Eligibility Category. If you entered the eligibility Telephone Number category (e)(26) in Question 16 above, please provide the receipt number of your H-1B principal spouse's most recent Form I-797 Notice of Approval for Form 1-129. Signature of Person Preparing Form, If Other Than Applicant 19. (c)(35) and (eX36) Eligibility Category I declare that this document was prepared by me at the request a. If you entered the eligibility category (c)(35) or (eX36) of the applicant and is based on all information of which I have in Question 16 above, please provide the receipt any knowledge. number of the Form I-140 beneficiary's Form I-797 Preparer's Signature Notice of Approval for Form I-140. b. Have you EVER been arrested for and/or convicted of Date of Signature (mm/dd/yyyy) any crime? ❑ Yes ❑ No Printed Name NOTE: If you answered "Yes" to Item Numbers 19.b., refer to Item Number 5., Item H. or Item I. in the Who May File Form 1-765 section of these Instructions for Address information about providing court dispositions. Form1-765 01/17/17 N Page 2 of 2 EFTA01699798 CONTINUED PRESENCE REQUEST PROCEDURES Listed below are all the documents necessary for Parole and Humanitarian Assistance Branch, Office of International Affairs at INS to approve requests for continued presence. One set of all documents listed in items 1-6 must be completed/provided by the SA for each victim of a severe form of trafficking, including juveniles. Once complete, the documents need to be forwarded to Melody Tiddle, Management/Program Analyst, Office for Victim Assistance at FBIHQ, Room 3329 who will complete the Law Enforcement Agency Certificate (Item #7) and forward the entire packet to PHAB, via FedEx. 1. Request for Continued Presence Form (template) (Signed by Case Agent and Supervisor) 2. INS Form I-102 (1-94 departure record) o Signed by Victim o Address — In care of: Case Agent's Name and Address o Original must be Submitted 3. INS Form 1-765 (employment authorization = EAD) o Signed by Victim o Item #3, do: Case Agents Name and Address o Original must be Submitted 4. 2 passport type photos (white background, glossy, unmounted, 2x2 full face photos) 5. 2 sets of fingerprints 6. Copy of the criminal records check 7. Law Enforcement Agency certification — Completed by OVA Please be sure to indicate within your submission the intended prosecutorial source of the case (categories below): • The US Attorney's Office, District, is handling the case and has concurred with this request. • The US Department of Justice, Criminal Division, Child Exploitation and Obscenity Section (CEOS), is handling the case and has concurred with this request; • The US Department of Justice, Civil Rights Division, Criminal Section, is handling the case and has concurred with this request; • The US Department of Justice, Criminal Division, Organized Crime and Racketeering Section is handling the case and has concurred with this request. • Other (please list) EFTA01699799 8/7/2013 CONTINUED PRESENCE EXTENSION REQUEST PROCEDURES It is the responsibility of the Case Agent to put tickler in file regarding CP Extensions. Requests for extension of continued presence must be submitted 30 days prior to the expiration of the individual's 1-94. When requesting an extension for continued presence, the SA must submit the following materials to OVA: 1. Request for Extension of Continued Presence Form (Template) 2. INS Form 1-765 (employment authorization = EAD) o Signed by Victim o Item #3, c/o: Case Agent's Name and Address o Original must be Submitted 3. INS Form 1-102 (I-94 departure record) Signed by Victim o Address — In care of•. Case Agents Name and Address o Original must be Submitted 4. 2 passport type photos (white background, glossy, unmounted, 2x2 full face photos) 5. Copy of the criminal records check 6. Law Enforcement Agency certification — Completed by OVA Once completed, SA is to forward the completed Request for Extension of Continued Presence Packet to Melody Tiddle, Management/Program Analyst, Office for Victim Assistance at FBIHQ, Room 3329 who will complete the Law Enforcement Agency Certificate and forward the entire packet to PHAB, via FedEx. EFTA01699800 8/7/2013 EFTA01699801