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Replace your lost or stolen Form I-94 or Form I-95; or
U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Services
OMB No. 1615-0079; Exp. 2/29/04
If you are a nonimmigrant in the United States, file this
application to:
Replace your mutilated Form I-94 or Form I-95; or
Receive an initial Form I-94 if you were not issued one
when you entered as a nonimmigrant, and you are filing
this form with an application for extension of stay or
change of status; or
Pur
p
ose of This Form.
Please answer all questions by typing or printing clearly in
black ink. If you need extra space to answer any item, attach a
sheet of paper with your name and your alien registration
number (A#), if any, and indicate the number of the item to
which the answer refers. You must file your application with
the required initial evidence. Every application must be
properly signed and filed with the correct fee. If you are under
14 years of age, your parent or guardian may sign the
application.
Translations. Any foreign language document must be
accompanied by a full English translation that a translator has
certified as complete and correct. The translator must also
certify that he or she is competent to translate the foreign
language into English.
Copies. If these instructions state that a copy of a document
may be filed with this application, and you choose to send us
the original, we may keep that original for our records.
If you are filing to replace a Form I-95, file this application at
the local BCIS office having jurisdiction over where you are
temporarily located.
Form I-94, Nonimmigrant Arrival-Departure Record
(includes also Form I-94W, Nonimmigrant Visa Waiver
Arrival-Departure Record); or
Form I-95, Crewman Landing Permit.
.
.
.
.
.
Receive an initial Form I-94 if you were not issued a Form
I-94 when you were originally admitted into the U. S. due
to your military membership as described below:
.
L
ost or Stolen Form. If you are applying to replace a lost or
stolen Form I-94 or Form I-95, submit a copy of the original or
submit a copy of the biographic page from your passport and a
copy of the page indicating admission as claimed, or other
evidence of your admission. If you are unable to submit this
evidence, submit a full explanation of why you cannot give any
of the above evidence, along with a copy of evidence of your
identity and copies of any evidence in your possession to
substantiate your claim. If your card was stolen, submit a copy
of the police report relating to the theft.
nonimmigrant member of the U.S. armed forces; or
--
nonimmigrant member of the North Atlantic Treaty
Organization (NATO) armed forces; or
--
--
nonimmigrant member of the Partnership for Peace
military program under the Status of Forces Agreement
(SOFA).
Who Ma
y
File?
Receive a corrected Form I-94 or Form I-95 if you were
issued one with incorrect information when you entered
as a nonimmigrant; or
.
General Filin
g
Instructions.
Initial Evidence.
N
onimmi
g
rant Militar
y
Member. If you are filing as a
nonimmigrant military member in the U.S. armed forces, NATO
or the Partnership for Peace program and you are requesting
an initial Form I-94, contact your foreign commander or his or
her designee in the United States for filing information.
Where to File.
First Form I-94. If you were not issued a Form I-94 at
admission and have not since been issued a Form I-94, but
now require a Form I-94 for another application you are filing,
submit a copy of any evidence in your possession to
substantiate your claimed admission.
M
utilated Form. If you are applying to replace a mutilated
Form I-94 or I-95, attach the original form.
This form is used by a nonimmigrant to apply to the Bureau of
Citizenship and Immigration Services (BCIS) for a new or
replacement:
To request BCIS to correct inaccurate information on your
Form I-94 or Form I-95, submit your application at the local
BCIS office having jurisdiction over where you are temporarily
located. Contact the local BCIS office for specific information
on how to file the application.
If you were not issued a Form I-94 at admission or are filing
this application with an application for extension of stay or
change of status, file this application where you are filing the
accompanying extension of stay or change of status
application.
If you are a nonimmigrant member of the U.S. armed forces, file
this application at the local BCIS office having jurisdiction
over the area where you are temporarily located.
If you are in a NATO or Partnership for Peace military program
under SOFA, and are seeking an initial Form I-94, submit this
application through your foreign commander or his or her
designee to NATO/Headquarters of the Supreme Allied
Commander, Atlantic (SACLANT).
I-102, Application for Replacement/Initial
Nonimmi
g
rant Arrival - De
p
arture Document
D
ocument With Incorrect In
f
ormation. If you want the BCIS
to correct inaccurate information on your Form I-94, attach the
Form I-94 to your Form I-102 application. If you check box
"g" on Part 2, Application Type, attach a statement dated and
signed by you, citing specifically what information on your
Form I-94 or Form I-95 copy requires correction. You must
also attach evidence verifying that the corrected information
is valid.
Form I-102 Instructions (Rev. 04/04/03)N (Prior versions may be used until 09/30/03)
(The BCIS is comprised of offices of the former Immigration
and Naturalization Service.)
If you are in Alabama, Arkansas, Florida, Georgia, Kentucky,
Louisiana, Mississippi, New Mexico, North Carolina,
Oklahoma, South Carolina, Tennessee or Texas, mail this
application to: BCIS Texas Service Center, P.O. Box
851182, Mesquite, TX 75185-1182.
If you are in Arizona, California, Guam, Hawaii or Nevada, mail
this application to: BCIS California Service Center, P.O. Box
10102, Laguna Niguel, CA. 92607-0040.
The fee for this application is $100.00. The fee must be
submitted in the exact amount. It cannot be refunded. DO
NOT MAIL CASH.
nitial processin
. Once the application has been accepted, it
will be checked for completeness, including submission of the
required initial evidence. If you do not completely fill out the
form or file it without required initial evidence, you will not
establish a basis for eligibility and we may deny your
application.
D
ecision. You will be notified in writing of the decision on
your application. If the application is approved, a new Form
I-94 or Form I-95 will be issued to you.
We try to create forms and instructions that are accurate, can
be easily understood and that impose the least possible
burden on you to provide us with information. Often this is
difficult because some immigration laws are very complex.
The estimated average time to complete and file this
application is as follows: (1) 5 minutes to learn about the law
and form; (2) 5 minutes to complete the form; (3) 15 minutes
to assemble and file the application -- for a total estimated
average of 25 minutes per application. If you have comments
regarding the accuracy of this estimate or suggestions for
making this form simpler, you may write to: Bureau of
Citizenship and Immigration Services, HQRFS, 425 I Street,
N
.W., Room 4034, Washington, DC 20536; OMB No.
1615-0079. DO NOT MAIL YOUR COMPLETED
APPLICATION TO THIS ADDRESS.
In all other instances, file your application as follows:
If you are in Connecticut, Delaware, District of Columbia,
Maine, Maryland, Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island,
Vermont, the Virgin Islands, Virginia or West Virginia, mail this
application to: BCIS Vermont Service Center, 75 Lower
Welden Street, St. Albans, VT 05479-0001.
Fee.
You do not need to pay the fee to request the BCIS to correct
your Form I-94 or Form I-95 copy if the error(s) on your
document was made by BCIS, through no fault of you own. If,
however, the error(s) was made because of information you
provided or failed to provide to the BCIS or the U.S.
Department of State, you must pay the fee.
All checks and money orders must be drawn on a bank or
other institution located in the United States and must be
payable in United States currency. The check or money order
should be made payable to the "Bureau of Citizenship and
Immigration Services," except that:
if you are in Guam and are filing this application in Guam,
make your check or money order payable to the
"Treasurer, Guam."
if you are in the U.S. Virgin Islands and are filing this
application in the U.S. Virgin Islands, make your check or
money order payable to the "Commissioner of Finance of
the Virgin Islands."
.
.
Checks are accepted subject to collection. An uncollected
check will render the application and any document issued
invalid. A charge of $30.00 will be imposed if a check in
payment of a fee is not honored by the bank on which it is
drawn.
If you are elsewhere in the United States, mail this application
to: BCIS Nebraska Service Center, P.O. Box 87102,
Lincoln, NE 68501-7102.
A
cceptance. Any application that is not signed or is not
accompanied by the proper fee, if required, will be rejected
with a notice that the application is deficient. You may
correct the deficiency and resubmit the application.
However, an application is not considered properly filed
until it is accepted by the BCIS.
Processin
g
Information.
Penalties.
If you knowingly and willfully falsify or conceal a material fact
or submit a false document with this request, we will deny the
benefit you are seeking and may deny any other immigration
benefit. In addition, you will face severe penalties provided
by law, and you may be subject to criminal prosecution and/or
removal from the United States.
Privac
y
Act Notice.
We ask for the information on this form and associated
evidence to determine if you have established eligibility for
the immigration benefit you are seeking. We may provide this
information to other government agencies. Failure to provide
this information and any requested evidence may delay a final
decision or result in denial of your request.
Pa
p
erwork Reduction Act Notice.
Information and BCIS Forms.
For information on immigration laws, regulations and
procedures and to order BCIS forms, call our National
Customer Service Center toll-free at 1-800-375-5283 or visit
our internet web site at www.bcis.gov.
You do not need to pay the fee if you are nonimmigrant
military member in the U.S. armed forces or you are
participating in a NATO or Partnership for Peace military
program under the SOFA and you are requesting an initial or
replacement Form I-94.
Form I-102 Instructions (Rev. 04/04/03)N (Prior versions may be used until 09/30/03) Page 2
Daytime Telephone Number (with area code)
Are you now in removal proceedings?
U.S. Department of Homeland Security
Bureau of Citizehsip and Immigration Services
Part 1. Information about
y
ou.
Part 2. Application type. (check one)
I am applying to replace my lost or stolen Form I-94 (I-94W).
Part 3. Processing information.
Are you filing this application with any other petition or application?
Signature. Read the information on penalties in the instructions before completing
this section. You must file this application while in the United States.
Part 5. Signature of person preparing form, if other than above. (Sign below)
I am applying to replace my lost or stolen Form I-95.
I am applying to replace Form I-94 because it is mutilated. I have attached my original I-94.
I am applying to replace Form I-95 because it is mutilated. I have attached my original I-95.
I was not issued a Form I-94 when I entered as a nonimmigrant, and I am filing this
application together with an application for an extension of stay/change of status.
I was issued a Form I-94 or Form I-95 with incorrect information, and I am requesting the
BCIS to correct the document.
a.
b
.
c.
d.
e.
g.
N
o
If
y
ou are unable to
p
rovide the ori
g
inal of
y
our Form I-94
,
g
ive the followin
g
information:
Yes - Form #
N
o
Yes (Attach an explanation on a separate sheet of paper.)
Part 4.
I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge.
START HERE - Please Type or Print
Action Block
Returned
Date
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
A
ttorney or Representative, if any.
To Be Completed By
Fill in box if G-28 is attached to
represent the applicant.
ATTY State License #
Applicant
Interviewed
on
New I-94 #
FOR BCIS USE ONLY
I was not issued a 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.
f.
I-102, Application for Replacement/Initial
Nonimmigrant Arrival - Departure Document
Form I-102 Form (Rev. 04/04/03)N (Prior versions may be used until 09/30/03)
Family Name Given Name Middle Name
Address - In care of -
Street Number and Name Apt./Suite #
City State or Province CountryZip/Postal Code
Date of Birth (mm/dd/yyyy) Country of Birth
Social Security # (if any) A # (if any)
Date of Last Admission (mm/dd/yyyy) Expires on (mm/dd/yyyy)
Current Nonimmigrant Status I-94, Arrival/Departure Document #
Class of
Admission:
Place of
Admission:
Your name exactly as it appears on Form I-94 or I-95, if known
S
i
g
natur
e
Date (mm/dd/yyyy)
Daytime Telephone Number (with area code)
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 which the Bureau of Citizenship and Immigration Services needs to
determine eligibility for the benefit I am seeking.
Firm Name and Address
S
i
g
natur
e
Print or Type Your Name
Date (MM/DD/YYYY)
Fax Number (if any)
OMB No. 1615-0079; Exp. 2/29/04
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