Fillable Form I-102: Application for Replacement/Initial Nonimmigrant Arrival-Departure Document (USCIS)

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Form I-102: Application for Replacement/Initial Nonimmigrant Arrival-Departure Document (USCIS)

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The Form I-102: Application for Replacement/Initial Nonimmigrant Arrival-Departure Document (USCIS) form is 6 pages long and contains:

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  • 36 check-boxes
  • 95 other fields

Country of origin: US
File type: PDF

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-102 Edition 11/08/19 Page 1 of 6
For
USCIS
Use
Only
Action Block
►
START HERE. Type or print in black ink
Part 1. Information About You
Application for Replacement/Initial Nonimmigrant
Arrival-Departure Document
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-102
OMB No. 1615-0079
Expires 11/30/2021
To Be Completed by an
Attorney or Accredited
Representative,
if any.
Select this box if Form
G-28 is attached to
represent the applicant.
Attorney State
License Number
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
New I-94 Number
Remarks
Receipt
ZIP Code
5.f.
State
5.e.
City or Town5.d.
Street Number and Name5.b.
5.c Ste. Flr.Apt.
If you answered "No" to Item Number 6., provide your
U.S. physical address in Item Numbers 7.a. - 7.f.
6. Is your current U.S. mailing address the same as your
U.S. physical address?
Yes No
►
A-
Alien Registration Number (A-Number)1.
USCIS Online Account Number (if any)2.
►
Your Full Legal Name
7.a.
U.S. Physical Address
In Care Of Name
ZIP Code
7.f.
State
7.e.
City or Town7.d.
Street Number and Name7.b.
7.c. Ste. Flr.
Apt.
Family Name
(Last Name)
4.a.
Given Name
(First Name)
4.b.
Middle Name4.c.
Provide all other names used. Include nicknames, aliases,
maiden name, and names from previous marriages. Provide
evidence of any name changes.
Other Names Used (if any)
5.a.
U.S. Mailing Address
In Care Of Name
8. Date of Birth (mm/dd/yyyy)
Other Information
10. Country of Citizenship
9. Country of Birth
Form I-102 Edition 11/08/19 Page 2 of 6
12.
(mm/dd/yyyy)
Date of Last Entry into the United States
Place of Last Entry into the United States (City and State)13.
Class of Admission at Last Entry Into the United States14.
15.
AirportLand border Seaport
Indicate the type of Port-of-Entry at which you last
entered the United States:
►
17. Date Status Expires (mm/dd/yyyy)
Form I-94, Form I-94W, or Form I-95 Arrival-Departure
Record Number
18.a.
Passport Number18.b.
Travel Document Number18.c.
18.d. Country of Issuance for Passport or Travel Document
18.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Current Nonimmigrant Status16.
19.b.
19.a. Family Name
(Last Name)
Given Name
(First Name)
Provide your name exactly as it appears on Form I-94, Form
I-94W, or Form I-95. If the name on the form is different than
your current legal name as entered in Part 1., Item Numbers
3.a. - 3.c, provide evidence of the name change.
19.c. Middle Name
I am applying to replace my Form I-95 because it was
mutilated. I have attached my original Form I-95.
1.d.
1.g. 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.f. I was issued Form I-94, Form I-94W, or Form I-95 by
USCIS with an error or incorrect information, and I
am requesting that USCIS correct the document. I
have attached my original Form I-94, Form I-94W, or
Form I-95.
1.e.
I was not issued Form I-94 when I was admitted by
CBP at a port-of-entry in the United States (whether
at a land border, airport, or seaport).
Provide an explanation of the error or incorrect
information entered on Form I-94, Form I-94W, or
Form I-95 at the time of issuance.
Part 3. Processing Information
1.a. Are you filing this application with any other petition or
application?
USCIS Form Number and Name 1.b.
NoYes
If you answered "Yes" to Items Number 1.a., provide the
USCIS form number and name of the application or
petition you are filing in Item Number 1.b.
1.c. I am applying to replace my Form I-94 or Form
I-94W because it was mutilated. I have attached my
original Form I-94 or Form I-94W.
11. U.S. Social Security Number (if any)
►
I am applying to replace my lost or stolen Form I-95.1.b.
Entry Information
Part 1. Information About You (continued) Part 2. Reason for Application
Select the box that best describes your reason for requesting an
initial or replacement document. (Select only one box)
1.a. I am applying to replace my lost or stolen Form I-94
or Form I-94W.
Form I-102 Edition 11/08/19 Page 3 of 6
Part 3. Processing Information (continued)
Are you now in removal proceedings? 2.a. NoYes
Provide detailed information regarding the proceedings.
If you need extra space to complete this section, use the
space provided in Part 7. Additional Information.
2.b.
If you answered "Yes" to Item Number 2.a., complete
Item Number 2.b.
Applicant's Statement
Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question, in
1.a.
a language in which I am fluent, and I understood
everything.
,
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
NOTE: Read the Penalties section of the Form I-102
Instructions before completing this section.
You must file Form I-102 while in the United States.
2.
At my request, the preparer named in Part 6.,
prepared this application for me based only upon
information provided or authorized.
,
3.
Applicant's Mobile Telephone Number (if any)4.
Applicant's Daytime Telephone Number
Applicant's Contact Information
5. Applicant's Email Address (if any)
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
Applicant's Certification
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.
Applicant's Signature
6.a. Applicant's Signature
6.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Part 5. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Provide the following information about the interpreter.
Form I-102 Edition 11/08/19 Page 4 of 6
Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number and Name3.a.
3.b. Ste. Flr.Apt.
3.h.
3.f. Province
Country
3.g. Postal Code
4.
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Daytime Telephone Number
6. Interpreter's E-mail Address (if any)
Interpreter's Contact Information
Interpreter's Certification
I certify under penalty of perjury, that:
which is the same language specified in Part 4., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Certification, and has
verified the accuracy of every answer.
I am fluent in English and
,
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Interpreter's Signature
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number and Name3.a.
3.b. Ste. Flr.Apt.
3.h.
3.f. Province
Country
3.g. Postal Code
Preparer's Full Name
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
Form I-102 Edition 11/08/19 Page 5 of 6
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
(continued)
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
7.a.
7.b.
beyond the preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared
this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or
she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's
Certification, and that all of this information is complete, true,
and correct. I completed this application based only on
information that the applicant provided to me or authorized me to
obtain or use.
Preparer's Statement
Preparer's Signature
NOTE: If you are an attorney or accredited representative, you
may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this
application.
Form I-102 Edition 11/08/19 Page 6 of 6
Part 7. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
3.d.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
3.a. 3.b. 3.c.Page Number Part Number Item Number
►
A-
A-Number (if any)2.
4.d.
4.a. 4.b. 4.c.Page Number Part Number Item Number
5.d.
5.a. 5.b. 5.c.Page Number Part Number Item Number
Item NumberPart NumberPage Number 7.c.7.b.7.a.
7.d.
6.d.
6.a. 6.b. 6.c.Page Number Part Number Item Number
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Form I-102: Application for ReplacementInitial Nonimmigrant Arrival-Departure Document (USCIS)

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Completed 18 July 2021

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