Part 1. Information About You (continued)
Part 3. Processing Information
1.a. Are you filing this application with any other petition or
Current Nonimmigrant Status
If "Yes" provide the USCIS Form Number and name of the
Date Status Expires
application or petition you are filing in Item Number 1.b.
USCIS Form Number and Name
Form I-94, I-94W, or I-95 Arrival-Departure Record Number
Are you now in removal proceedings?
If "Yes" complete Item Number 2.b.
Travel Document Number
Provide detailed information regarding the proceedings.
If you need extra space to complete any item, attach a
15.d. Country of Issuance for Passport or Travel Document
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
15.e. Expiration Date for Passport or Travel Document
Number to which your answer refers; and date and sign
Part 2. Reason for Application
Select the box that best describes your reason for requesting an
initial or replacement document. (Select only one box)
I am applying to replace my lost or stolen Form I-94
I am applying to replace my lost or stolen Form I-95.
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.
If you are unable to provide the original of your Form I-94,
I am applying to replace my Form I-95 because it was
I-94W, or I-95, provide the following information:
mutilated. I have attached my original Form I-95.
I was not issued Form I-94 when I was admitted by
NOTE: Provide your name exactly as it appears on Form I-94,
CBP at a port-of-entry in the United States (whether
I-94W, or I-95.
at a land border, airport, or seaport).
3.a. Family Name
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.
3.c. Middle Name
I was not issued Form I-94 when I entered as a
Class of Admission at Last Entry into the United States
nonimmigrant member of the military, and I am filing
this application for an initial Form I-94.
Place of Last Entry into the United States (City and State)
Form I-102 10/19/17 N
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