Declaration Under Penalty of Perjury

							                         Declaration Under Penalty of Perjury


I __________________,

Hereby declare that I was a victim of human trafficking, where I was subjected to one of
the following:

1) Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion
or in which the person induced to perform such an act is under 18; or

2) the recruitment, harboring, transportation, provision, or obtaining of a person for labor
or services, through the use of force, fraud, or coercion, for the purpose of subjecting
that person to involuntary servitude, peonage, debt bondage, or slavery.

I declare under penalty of perjury that the foregoing statement is true and correct, and I
am aware that if I present any material matter as true which I know to be false, I may be
subjected to penalties prescribed for perjury under the Penal Code of the State of
California in accordance with Section 11054 of the Welfare and Institutions Code.


Executed at _____________________ California, this ___ day of ______, 2008


Applicant’s Signature_________________________________