Fillable Ins-form-i-102 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document

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Ins-form-i-102 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document

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The Ins-form-i-102 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document form is 4 pages long and contains:

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  • 35 check-boxes
  • 73 other fields

Country of origin: US
File type: PDF

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Form I-102 10/15/14 N
Action Block
For
USCIS
Use
Only
►
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
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
USCIS
Form I-102
OMB No. 1615-0079
Expires 10/31/2017
New I-94 Number
Remarks
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
Receipt
4.a.
U.S. Mailing Address
In Care Of Name
ZIP Code
4.f.
State
4.e.
City or Town4.d.
Street Number
and Name
4.b.
►7. (mm/dd/yyyy)Date of Birth
4.c. Apt.
Flr.Ste.
Other Information
9. Country of Citizenship
10. U.S. Social Security Number (if any)
►
8. Country of Birth
If you answered "No" to Item Number 5., provide your
U.S. physical address in Item Numbers 6.a. - 6.f.
5. 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 ELIS Account Number (if any)2.
►
Your Full Name
6.a.
U.S. Physical Address
In Care Of Name
ZIP Code
6.f.
State
6.e.
City or Town6.d.
Street Number
and Name
6.b.
6.c. Apt.
Flr.Ste.
11.
►(mm/dd/yyyy)
Date of Last Entry into the United States
Place of Last Entry into the United States (City and State)12.
Entry Information
Page 1 of 4
Form I-102 10/15/14 N
►
14.
►(mm/dd/yyyy)
Date Status Expires
Form I-94, I-94W, or I-95 Arrival-Departure Record Number15.a.
Passport Number15.b.
Travel Document Number15.c.
15.d. Country of Issuance for Passport or Travel Document
15.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy) ►
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-95.1.b.
I am applying to replace my lost or stolen Form I-94
or I-94W.
1.c.
I am applying to replace my Form I-95 because it was
mutilated. I have attached my original Form I-95.
1.d.
I am applying to replace my Form I-94 or I-94W
because it was mutilated. I have attached my original
Form I-94 or I-94W.
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, I-94W, or I-95 with incorrect
information, and I am requesting that USCIS correct the
document. I have attached my original Form I-94,
I-94W, or 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).
Are you now in removal proceedings? 2.a. NoYes
Provide detailed information regarding the proceedings.
If you need extra space to complete any item, attach a
separate sheet of paper; type or print your name and
A-Number (if any) at the top of each sheet of paper;
indicate the Page Number, Part Number, and Item
Number to which your answer refers; and date and sign
each sheet.
2.b.
If "Yes" complete Item Number 2.b.
3.b.
3.a. Family Name
(Last Name)
Given Name
(First Name)
NOTE: Provide your name exactly as it appears on Form I-94,
I-94W, or I-95.
If you are unable to provide the original of your Form I-94,
I-94W, or I-95, provide the following information:
3.c. Middle Name
4.
Place of Last Entry into the United States (City and State)5.
Class of Admission at Last Entry into the United States
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 "Yes" provide the USCIS Form Number and name of the
application or petition you are filing in Item Number 1.b.
Current Nonimmigrant Status13.
Page 2 of 4
Form I-102 10/15/14 N
Applicant Certification
I certify, under penalty of perjury, that the foregoing is true
and correct. Copies of documents submitted are exact
photocopies of unaltered original documents, and I
understand that I may be required to submit original
documents to U.S. Citizenship and Immigration Services
(USCIS) at a later date. Furthermore, I authorize the release
of any information from my records that USCIS may need to
determine my eligibility for the benefit that I seek. I
furthermore authorize release of information contained in this
form, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the
administration of U.S. immigration laws.
,
2. I have requested the services of and consented to
who is
representative, preparing this form for me.
is not an attorney or accredited
3.a. Applicant's Signature
3.b. Date of Signature (mm/dd/yyyy) ►
4.
Applicant's Mobile Telephone Number5.
Applicant's Daytime Telephone Number
6. Applicant's E-mail Address
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f. Province
Country
3.g. Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's E-mail Address5.
Part 5. Contact Information, Certification, and
Signature of the Interpreter
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 concerning the interpreter:
Part 4. Statement, Certification, Signature, and
Contact Information of the Applicant
I can read and understand English, and have read and
understand every question and instruction on this
form, as well as my answer to every question.
1.b.
The interpreter named below has read to me every
question and instruction on this form, as well as my
answer to every question, in
1.a.
a language in which I am fluent. I understand every
question and instruction on this form as translated
to me by my interpreter, and have provided true
and correct responses in the language indicated
above.
,
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Applicant's Contact Information
Page 3 of 4
Form I-102 10/15/14 N
Preparer's Full Name
Provide the following information concerning 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 Name2.
Preparer's Mailing Address
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's E-mail Address
5. Preparer's Fax Number
I am not an attorney or accredited representative but
have prepared this form on behalf of the applicant
and with the applicant's consent.
7.a.
7.b.
beyond the preparation of this form.
I am an attorney or accredited representative and my
representation of the applicant in this case
(choose one) extends does not extend
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f. Province
Country
3.g. Postal Code
NOTE: If you need extra space to provide any additional
information, 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 date and sign each sheet.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy) ►
Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the applicant. I completed the
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with every
answer provided for every question on the form and, when
required, supplied additional information to respond to a
question on the form.
Part 5. Contact Information, Certification, and
Signature of the Interpreter (continued)
Interpreter Certification
I certify that:
is the same language provided in Part 4., Item Number 1.b.;
I am fluent in English and which
►(mm/dd/yyyy)Date of Signature6.b.
Interpreter's Signature6.a.
I have read to this applicant every question and instruction on
this form, as well as the answer to every question, in the
language provided in Part 4., Item Number 1.b.; and
The applicant has informed me that he or she understands every
instruction and question on the form, as well as the answer to
every question.
,
Page 4 of 4
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Ins-form-i-102 Application for ReplacementInitial Nonimmigrant Arrival-Departure Document

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Completed 2 July 2020

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