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Application For Replacement-Initial Nonimmigrant Arrival-Departure Document I-102 - Official Federal Forms
| Application For Replacement-Initial Nonimmigrant Arrival-Departure Document Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services Receipt Action Block USCIS Form I-102 OMB No. 1615-0079 Expires 02/28/2015 To Be Completed by an Attorney/Representative, if any. Fill in box if G-28 is attached to represent the applicant. Attorney State License Number: For USCIS Use Only New I-94 Number Remarks Start Here. Type or Print in Black Ink NOTE: Review instructions for detailed information on completing this form. Part 1. Information About You 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 5. Country of Birth 6. Country of Citizenship Mailing Address 2.a. In Care of Name 7. U.S. Social Security Number, if any 8. 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 9. Date of last admission to the United States (mm/dd/yyyy) Place of last admission to the United States 2.d. City or Town 2.e. State 2.g. Postal Code 2.h. Province 2.i. 3. Country Alien Registration Number (A-Number) 11. 12. Status expires (mm/dd/yyyy) 2.f. Zip Code 10. What is your current Nonimmigrant Status? Provide your Form I-94, I-94W, or I-95 Arrival-Departure Record Number A4. Date of Birth (mm/dd/yyyy) Form I-102 02/17/13 N Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Reason for Application Check the box that best describes your reason for requesting an initial or replacement document. (Check only one) 1.a. 1.b. 1.c. I am applying to replace my lost or stolen Form I-94 or I-94W. I am applying to replace my lost or stolen Form I-95. I am applying to replace Form I-94 or I-94W because it has been mutilated. I have attached my original Form I-94 or I-94W. I am applying to replace Form I-95 because it has been mutilated. I have attached my original Form I-95. 1.f. 1.e. I was not issued Form I-94 at admission, or I am filing this application together with Form I-539, Application to Extend/Change Nonimmigrant Status for an extension of stay/change of status. I was issued Form I-94, I-94W, or I-95 with incorrect information, and I am requesting USCIS to correct the document. I have attached my original Form I-94, I-94W, or I-95. I was not issued Form I-94 when I entered as a nonimmigrant member of the military, and I am filing this application for an initial Form I-94. 1.g. 1.d. Part 3. Processing Information 1.a. Are you filing this application with any other petition or application? (If "Yes" provide the USCIS Form Number and Name of the application or petition you are filing concurrently in number 1.b.) Yes No 1.b. USCIS Form Number and Name 2.a. Are you now in removal proceeding? (If "Yes" complete number 2.b.) Yes No 2.b. Provide detailed information regarding the proceedings. If you need more space, use a separate sheet of paper. You must include your name and Alien Registration Number at the top of each sheet. If you are unable to provide the original of your Form I-94, I-94W, or I-95, provide the following information: NOTE: Provide your name exactly as it appears on Form I-94, I-94W, or I-95. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Class of Admission 5. Place of Admission Part 4. Signature of Applicant I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. 1.a. Signature of Applicant 1.b. Date of Signature (mm/dd/yyyy) 2. Daytime Phone Number ( ) - NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, your application may be denied. Form I-102 02/17/13 N Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 5. Signature of Person Preparing Form, If Other Than Applicant NOTE: If you are an attorney or representative, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with this application. 4. Preparer's Daytime Phone Number Extension ( 5. ) - Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name) Preparer's E-mail Address (if any) Declaration To be completed by all preparers, including attorneys and authorized representatives: I declare that I prepared this benefit request at the request of the applicant, that it is based on all the information of which I have knowledge, and that the information is true to the best of my knowledge. 6.a. Signature of Preparer 6.b. Date of Signature (mm/dd/yyyy) NOTE: If you require more space to provide any additional information, use a separate sheet of paper. You must include your name and Alien Registration Number at the top of each sheet. 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.f. Postal Code 3.e. Zip Code 3.g. Province 3.h. Country Form I-102 02/17/13 N Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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