I-102, Application for Replacement/Initial Nonimmigrant Arrival - Departure Document (United States)
This form is to apply for a replacement or initial nonimmigrant arrival/departure document to the United States Citizenship and Immigration Services. The form provided here is simply a sample of what the actual Form I-102 looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-129, Petition for a Nonimmigrant Worker
START HERE - Please type or print in black ink.
Part 1. Information about you.
1. Family Name _______________________________
Given Name _______________________________
Middle Name _______________________________
Address - In care of - _______________________________
Street Number and Name _______________________________
Apt./Suite # _______________________________
City _______________________________
State _______________________________
Zip/Postal Code _______________________________
Country _______________________________
Date of Birth (mm/dd/yyyy) _______________________________
Country of Birth _______________________________
Country of Citizenship/Nationality _______________________________
A # (if any) _______________________________
U.S. Social Security # _______________________________
Date (mm/dd/yyyy) and Place of Last Admission _______________________________
Current Nonimmigrant Status _______________________________
Status Expires on (mm/dd/yyyy) _______________________________
I-94, I-94W or I-95 Arrival/Departure Document # _______________________________
Part 2. Reason for application.
Check the box that best describes your reason for requesting a replacement document. (Check one box.) 1. Requested Nonimmigrant Classification. (Write classification symbol): _______________________________ 2. Basis for Classification (Check one): a. ____ I am applying to replace my lost or stolen Form I-94 (or I-94W). b. ____ I am applying to replace my lost or stolen Form I-95. c. ____ I am applying to replace Form I-94 (or I-94W) because it is mutilated. I have attached my original I-94 (or I-94W). d. ____ I am applying to replace Form I-95 because it is mutilated. I have attached my original I-95. e. ____ 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. f. ____ I was issued a Form I-94, I-94W or Form 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 Form I-95. g. ____ 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. Part 3. Processing information. 1. Are you filing this application with any other petition or application? ____ No ____ Yes - Form # _______________________________ 2. Are you now in removal proceedings? ____ No ____ Yes (Give detailed information regarding the proceedings. If you need more space to complete the answer, use a separate sheet(s) of paper. Write your name and A #, if any, and "Part 3, Number 2" at the top of each sheet.) _______________________________ 3. If you are unable to provide the original of your Form I-94, I-94W or I-95, give the following information: Your name exactly as it appears on Form I-94, I-94W or I-95, if known (print clearly) _______________________________ Class of Admission: _______________________________ Place of Admission: _______________________________ 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 the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. Signature _______________________________ Daytime Telephone Number (with area code) _______________________________ Date (mm/dd/yyyy) _______________________________ Please Note: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you cannot be found eligible for the requested document and this application may be denied. 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. Signature _______________________________ Print or Type Your Name _______________________________ Firm Name _______________________________ Firm Address (Street Number and Name or P.O. Box, City, State, Zip Code) _______________________________ Daytime Telephone Number (with area code)_______________________________ Date (mm/dd/yyyy) _______________________________ ----------------------------- FOR USCIS USE ONLY Returned ___________________ Date Resubmitted ___________________ Date Reloc Sent ___________________ Date Reloc Rec'd ___________________ Date ____ Applicant Interviewed on ___________________ Receipt ___________________ New I-94 # ___________________ Remarks ___________________ Action Block To Be Completed by Attorney or Representative, if any ____ Fill in box if G-28 is attached to represent the applicant ATTY State License # ___________________
Part 4. 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)
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