1 Request for HHS Certification of Foreign National Adult

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OMB Control Number: 0970-0454
Expiration date: XX/XX/XXXX

Request for HHS Certification of Foreign National Adult Victims of Human Trafficking
HHS provides letters of Certification and Eligibility to foreign national victims of severe forms of trafficking in
persons under the authority of the Trafficking Victims Protection Act (TVPA) of 2000, as amended, 22 U.S.C.
Section 7105(b)(1)(C) and (E). This form can be used to provide information to obtain a Certification Letter from
HHS. Certification is required for foreign national adult victims in the United States to apply for federally funded
benefits and services. More information about the Certification process can be found online at https://
www.acf.hhs.gov/otip/victim-assistance/certification.
This form is not an application and use of this form is optional. Requests for HHS Certification can be
submitted online through the Shepherd Case Management System. If you do not wish to submit your request
through Shepherd or this form and would like to obtain an HHS Certification Letter, please contact an HHS
Trafficking Specialist at 866-401-5510 or via email at Trafficking@acf.hhs.gov.
Do not use this form for minors with Continued Presence or a T Nonimmigrant visa. To obtain an HHS
Eligibility Letter for a foreign national trafficking victim under 18 years of age, contact ChildTrafficking@acf.hhs.gov
for assistance.
INSTRUCTIONS AND OVERVIEW FOR CERTIFICATION PROCESS
1. Please read entire form before completing it.
2. Fill out all sections that apply to the person who experienced trafficking.
3. Send the completed form and supporting documentation (e.g. T-1 Nonimmigrant Status (T-1 Visa)
to Trafficking@acf.hhs.gov with the subject line as "HHS Certification Request." To protect the
client's privacy, do not include personally identifiable information (PII) about the client, such as the
client's name, alien number, or date of birth in the subject line or body of the emails.
4. To further protect the confidentiality of the communication, you can transmit the form as a
password-protected PDF and send the password in a separate email to Trafficking@acf.hhs.gov.
HHS will issue a Certification Letter after receiving the information provided in this form and the supporting
document. If HHS needs additional information, an HHS representative will contact you.
Questions? Contact an HHS Trafficking Specialist at 866-401-5510 during regular business hours, Monday through
Friday, 8:00 a.m. to 5:00 p.m. Eastern Time, or email Trafficking@acf.hhs.gov.
The National Human Trafficking Hotline is available 24 hours a day, 7 days a week for technical assistance and
service referrals at 1-888-373-7888.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Section 1: Client's Information
Last Name:

First Name:

Middle/Other Name:

Date of Birth:

Alien Number:

Country of Origin:

Gender:

Primary Language:

Male
Female

Emergency Concerns:

Unspecified, or another gender

Please describe any emergency concerns or considerations
(e.g. physical or mental health needs, housing considerations,
status if currently experiencing trafficking or other exploitative
situations, imminent court proceedings, or other significant
concerns)

Type of Trafficking Experienced:
Sex
Labor
Sex and Labor
Not Reported

Current City:
Current State:
Current Zip Code:
Department of Homeland Security Documentation:
Individuals can only receive an HHS Certification Letter if they have current Continued Presence, T-1 Nonimmigrant
Status, or a Bona Fide T-1 Visa from the Department of Homeland Security (DHS) that has not been rescinded or
denied. If you have a copy of a valid DHS document, please upload it and indicate what type of document you are
submitting below. If you do not have a copy, simply skip to the next section. No upload is required.
Continued Presence
T-1 Nonimmigrant Status
Bona Fide T-1 Visa

Section 2: Requester's Information
Enter the requester's information (the client OR the individual submitting the request on behalf of the client).

Last Name:

First Name:

Title:

Agency/Organization Name:
Phone Number:

Address:

Extension:

City:

Email:

Zip Code:

State:

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Section 3: Case Management Services
HHS funds trafficking-specific comprehensive case management services for foreign nationals who have
experienced trafficking and are seeking HHS Certification, as well as for certain eligible family members.
Are you or your client requesting trafficking-specific comprehensive case management services at this time?

Yes
No

Please note, you can submit new information if you or your client require case management services at a later time.

Section 4: Request for HHS Certification Letter
Are you or your client requesting an HHS Certification Letter at this time?
Yes
No
Please note, you can submit new information if you or your client would like to receive the Certification Letter at a
later time.
Who should receive the hard copy of the letter? Please indicate below and provide their mailing address.
Client

Benefits Start Date:

Requester

Please indicate the preferred date for the client's
certification for benefits to begin.

Other

Letter Recipient Organization:
Letter Recipient Last Name:
Letter Recipient First Name:
Letter Recipient Address:
City:

State:

Zip Code:

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Important Notice Regarding Information Sharing
If this form is not in the client's primary language or if the client is unable to read or understand the form, the
requester should read and explain the form to the individual in their primary language or use a qualified interpreter
to do so. This notification is intended to inform the client of how the information provided will be used by the
Department of Health and Human Services (HHS).
HHS is a federal government agency that is responsible for identifying and assisting potential victims of human
trafficking. HHS provides letters of certification and eligibility to foreign national victims of severe forms of
trafficking in persons under the authority of the Trafficking Victims Protection Act of 2000 (TVPA), as amended 22
U.S.C. Section 7105(b)(1)(C) and (E). These letters make foreign national victims of severe forms of trafficking in
persons eligible to receive federal and state benefits to the same extent as a refugee.
HHS will use the information collected in the HHS Certification form for one or more of the following purposes, and
to comply with the TVPA of 2000, as amended:
1.
2.
3.

To coordinate the delivery of a HHS Certification Letter to a foreign national adult present in the United States
who has been subjected to a severe form of trafficking in persons;
To refer a foreign national adult victim of trafficking in the United States to a case manager to assist
the person in obtaining needed benefits and services; and
To report aggregated data on trafficking victims assisted by HHS in federal reports and to the public.

Security of Client's Personal Information
The personally identifiable information (PII) that is shared with HHS through this form will be stored securely.
Information gathered, including PII, will remain in HHS' custody for 15 years. After 15 years, such records will be
transferred to the National Archives of the United States under the HHS record disposition authority, unless
required for business use by HHS. The records will be stored securely indefinitely. HHS uses the information to
evaluate and determine the certified client's eligibility for benefits, for consultation purposes, for reporting
requirements, and for research and analysis in anonymous datasets. To protect the privacy of clients, HHS will
never share any PII such as the client's name or alien number in reports or publicly available data sets. The
information contained in the form may be disclosed for a legitimate law enforcement purpose, including in response
to a discovery request or otherwise in the course of criminal or civil litigation. If you have any questions about this
form, you may contact a HHS Trafficking Specialist at 866-401-5510 or Trafficking@acf.hhs.gov.
By signing this form, you acknowledge that the client gives consent to share the information contained in the HHS
Certification form as necessary to obtain HHS Certification and for reporting purposes. The client acknowledges
that they have been notified that their information will be used in federal reports or data available to the public in a
way that does not disclose PII.
By signing this form, you acknowledge that the client has been informed that the information provided in this form
might be shared with other federal agencies as part of aggregate data reporting, and with public and
nongovernmental organizations for the purpose of confirming eligibility for benefits, or for processing referrals for
case management services.
Requester's Signature: ____________________________________________
Date: _____________________________

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