Written by attorney Nikki Mehrpoo Jacobson



[These instructions ask for quite a bit of detailin order to paint a clear picture for an adjudicator sitting at a desk in Vermont. The evidence standard for U Nonimmigrant Status is “any credible evidence," and the detail helps an adjudicator determine that the information in the declaration is credible. Your client’s story may not resemble this outline, but we recommend this level of detail as you work together with her to tell it.]

Declaration of ___________________

In Support of Application for U Nonimmigrant Status

I, _____________________ declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge:

My name is ________________ I was born on _______________ in _______________________________. I came to the United States in _________________


I am applying for U Nonimmibrant status because I was a severe domestic violence that caused serous injuries and left me traumatized. I helped the police (and/or prosecution) and ________________________________ (what happened? Abuser arrested? Convicted? Deported? Now you are safe?)

On ____________________, I called the police because ______________ ___________________ (what he did, e.g. pushed me, broke my cell phone when I tried to use it to call police, and then punched me.) The police came and _________________________.


One sentence on whether there were other incidents of abuse before this.

One sentence about what led to this incident

As many paragraphs as you need to discuss very specific details of the crime. Give at least two details about each aspect, including:

  • Where did the altercation start? Did it stay there or move to another place?

  • Where were the abuser and you in relation to each other throughout the incident?

  • What exactly did the perpetrator say during the assault (three specific words)?

-How did perpetrator assault and injure you? Hit, choke, punch, shove, etc.

-What was the impact on you? E.g., did you stumble or fall or bang into something?

Immediately after the assault, what happened? Did something happen to make it end?

  • Did the perpetrator say anything afterward? Apologize? Blame you?

  • Did you say anything afteward? What?

  • Did either of you leave?

Discuss interactions with police in detail.

  • The call to the police. Who called the police?

  • If it was you, how did you communicate with the operator?

  • What did you say?

  • What did the operator say?

  • HOW LONG did it take police to arrive?

  • Communication with police at the scene.

  • How many officers were there?

  • How were you and police officers able to communicate?

  • Was an interpreter available? How?

  • Spanish fluent officer?

  • Language access line?

  • Family member? Who?

  • Friend or neighbor

  • What specific questions did the police ask?

  • Please give at least three specific words they used.

  • What specific answers did you give?

  • Please give at least three specific words you used

  • Did you tell police about other incidents?

  • What did you say?

  • Did the police give you an emergency protective order? What did they say about it?

  • Are there problems with the police report that contradict your story?

  • [You can use the Police Report Clarification memo to go through problems, and then address why it's not accurate. Note that this is just for correcting a misstatement or misinterpretation in the police report, rather than explaining lack of cooperation, although the two are sometimes interconnected.)

What happened with the arrest?

  • Did you say you wanted the perpetrator arrested?

  • Did you say you wanted the perpetrator “charged" or that you wanted to press charges?

  • How did they ask?

  • What did you think they meant?

  • What did you say exactly?

Follow Up: abuser's criminal case

  • Was the perpetrator arrested?

  • Did an investigator from the police department call you?

  • Was the call in your language?

  • If not, what did you do?

  • Did you call back?

  • What happened when you called back?

  • Was the perpetrator jailed?

  • How long was he in jail?

  • Was he deported? - Before or after charges were brought against him?

  • Were charges brought against him (was he ordered to go to court?

  • Was the applicant subpoenaed to go to court?)

  • Was you contacted by the District Attorney’s office?

  • By who? A Victim Advocate or attorney?

Then what happened with your abuser's case?

  • Did you get a subpoena?

  • Did you go to court? For more than one day? How long?

  • Was you asked to testify?

  • Did you testify? What happened?

What happened with the abuser afterward

  • Did a domestic violence advocate call you? If so, what happened?

  • Did you get a Temporary Restraining Order?

  • Did you get a Restraining Order After Hearing?

  • Has the perpetrator violated the RO?

  • If so, did you call the police?

  • What happened?

  • If you let him come back, why?

  • Then what happened?

I suffered substantial abuse from the domestic violence against me.

Abuse fromthisincident

  • Physical injury

  • Please give three words for the type of pain. For example, did it:

Sting, burn, ache, throb, dull, sharp, constant,

  • How much did the injuries hurt? For example,

Excruciating, racking, agonizing, deep, intense,

  • How long did the pain last?

An hour? Half a day? A day? Several days? A week? More than a week?

  • Will the injury last for a very long time, like a scar or long-term damage to some part of your body?

  • Did the injury prevent you from working or any other activities? What kinds of things?

Emotional harm

  • Can you give five words for how you felt? For example, angry, sad, helpless, hopeless (You can refer to a list of words that some abused people use to describe the way they felt.)

  • Was control over you part of the abuse? Can you say how much of your life he controlled? All of it? Part of it? Did you feel like you had any control over your own life? (You can refer to the Power and Control wheel if it is useful)

  • How has your life been affected? For example, are you afraid to go out, are you distrustful? (You can refer to the Trauma checklist factors

Please grant a waiver of my immigration violations.

I am applying for a waiver of my unlawful entry to the U.S. Because if I am not given a waiver, I can’t get U Nonimmigrant Status. I am otherwise eligible for the U visa because as I have described above, I was a victim of __________ and I was helpful to _______________________________. I am protected in the United States, but I would not be in [home country]. It is also in the public interest to waive my violation because I would suffer hardships if I had to leave the U.S., and I believe I contribute to my community.

  • Give three examples of how you and your children would suffer if you had to leave the U.S.

  • Describe how you and they would suffer if they had to stay in US without you

  • Describe how you and they would suffer if they had to leave the U.S. with you

  • Give three examples of how you are a good parent, worker, community member

Signed this___day of _____ in _______________________


Nikki Mehrpoo Jacobson Attorney at Law / Professor of Law [email protected] THE JACOBSON LAW FIRM, APC Immigration & Nationality ǀ Workers' Compensation 510 West 6th St. Suite 326 Los Angeles , CA 90014 (310) 277-2266 (310) 277-3366 FAX Los Angeles Immigration Lawyers - Free Consultation

Additional resources provided by the author

Nikki Mehrpoo Jacobson Attorney at Law / Professor of Law [email protected] THE JACOBSON LAW FIRM, APC Immigration & Nationality ǀ Workers' Compensation 510 West 6th St. Suite 326 Los Angeles , CA 90014 (310) 277-2266 (310) 277-3366 FAX Los Angeles Immigration Lawyers - Free Consultation

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