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New York State Human Trafficking Referral Form

Referral of Human Trafficking Victim

Social Services Law § 483-cc requires that this form be completed and sent to the Division of Criminal Justice Services and the Office of Temporary and Disability Assistance as soon as practicable after a first encounter with a person who reasonably appears to be a human trafficking victim.

Please contact the NYS Division of Criminal Justice Services by email at if you encounter difficulty completing or have questions regarding the form.

***After submission, you will not be able to view your entry. Please save work before submission in a secure location on your own device. 
This question requires a valid date format of MM/DD/YYYY.
5. Please check one or both *This question is required.
8. Is the victim willing to assist in the investigation/prosecution of trafficker(s)? *This question is required.
9. Was the victim arrested? *This question is required.