"U-Visa Certification Application Form" - New York City

U-Visa Certification Application Form is a legal document that was released by the New York City Department of Consumer Affairs - a government authority operating within New York City.

Form Details:

  • Released on July 3, 2019;
  • The latest edition currently provided by the New York City Department of Consumer Affairs;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York City Department of Consumer Affairs.

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Download "U-Visa Certification Application Form" - New York City

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U-VISA CERTIFICATION APPLICATION FORM
Name
Mailing Address
Date of Birth
Name of Legal Representative
DCA Complaint Number
The Department of Consumer Affairs may certify a U-Visa application where the applicant: (a) was the
victim of qualifying criminal activity; (b) possesses information about qualifying criminal activity; and (c)
has been, is being, or is likely to be helpful in DCA’s detection, investigation, or prosecution of qualifying
criminal activity.
Please provide all the information requested below and include with this application any
supportive documents. Please email application and documents to
u-visa@dca.nyc.gov
1. Have you been a victim of “qualifying criminal activity,” as defined by 8 U.S.C §
1101(a)(15)(U)(iii)?
Yes
No
2. If yes, identify the criminal activity.
3. What are/were the dates of the criminal activity?
4. Who is/was the perpetrator of the criminal activity?
7/3/19
U-VISA CERTIFICATION APPLICATION FORM
Name
Mailing Address
Date of Birth
Name of Legal Representative
DCA Complaint Number
The Department of Consumer Affairs may certify a U-Visa application where the applicant: (a) was the
victim of qualifying criminal activity; (b) possesses information about qualifying criminal activity; and (c)
has been, is being, or is likely to be helpful in DCA’s detection, investigation, or prosecution of qualifying
criminal activity.
Please provide all the information requested below and include with this application any
supportive documents. Please email application and documents to
u-visa@dca.nyc.gov
1. Have you been a victim of “qualifying criminal activity,” as defined by 8 U.S.C §
1101(a)(15)(U)(iii)?
Yes
No
2. If yes, identify the criminal activity.
3. What are/were the dates of the criminal activity?
4. Who is/was the perpetrator of the criminal activity?
7/3/19
5. Where did the criminal activity occur?
6. Describe any injuries you suffered as a result of the criminal activity.
7. Describe the information you possess regarding the criminal activity.
8. Describe how you have been helpful or will be helpful in the investigation or prosecution of the
criminal activity.
9. Provide any additional description regarding the criminal activity. You can add extra pages to this
application to complete your answers, as necessary.
Applicant Signature
Print Name
Date
Legal Representative Signature
Print Name
Date
7/3/19
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