Fillable Form I-131a - Application For Travel Document (Carrier Documentation) (Page 2 of 5) in pdf

Part 1. Information About You (continued)

5.b.

Date Issued (mm/dd/yyyy)

5.c.

Disposition (attached, lost, etc.):

11.

Country of Birth

12.

Country of Citizenship or Nationality

Part 4. Applicant's Statement, Contact

Information, Certification, and Signature

Part 2. Reason for Application

NOTE: Read the Penalties section of the Form 1-131A

Instructions before completing this part.

(Select only one box):

1.a.

My previous Permanent Resident Card has been lost,

Applicant's Statement

stolen, or destroyed

NOTE: Select the box for either Item Number 1.a. or 1.b.

1.b.

My previous Permanent Resident Card was issued but

If applicable, select the box for Item Number 2.

never received

1.a.

I can read and understand English, and I have read

1.c.

My existing Permanent Resident Card has been

and understand every question and instruction on this

mutilated

application and my answer to every question.

1.d.

My existing Permanent Resident Card has already

1.b.

The interpreter named in Part 5. read to me every

expired

question and instruction on this application and my

answer to every question in

1.e.

Other (explain below):

a language in which I am fluent and I understood

everything.

Part 3. Processing Information

At my request, the preparer named in Part 6.,

Date Departed the United States (mm/dd/yyyy)

prepared this application for me based only upon

information I provided or authorized.

Date of Intended Travel to the United States

(mm/dd/yyyy)

Applicant's Contact Information

Are you NOW, or were you EVER, in exclusion,

Applicant's Daytime Telephone Number

deportation, removal, or rescission proceedings?

Yes

Applicant's Mobile Telephone Number (if any)

If you answered "Yes" to Item Number 3., provide

details in the space provided in Part 7. Additional

Information.

Applicant's Email Address (if any)

Since you were granted permanent residence, have you

EVER filed Form I-407, Abandonment of Lawful

Permanent Resident Status, or otherwise been judged to

Applicant's Certification

have abandoned your status?

Yes

Copies of any documents I have submitted are exact

If you answered "Yes" to Item Number 4., provide

photocopies of unaltered, original documents, and I understand

details in the space provided in Part 7. Additional

that USCIS may require that I submit original documents to

Information.

USCIS at a later date. Furthermore, I authorize the release of

5.a.

Have you EVER been issued a Travel Document?

any information from any and all of my records that USCIS

Yes

may need to determine my eligibility for the immigration

benefit I seek.

If you answered "Yes" to Item Number 5.a., answer Item

Numbers 5.b. and 5.c. for the last document issued to you

I furthermore authorize release of information contained in this

and provide additional details in the space provided in

application, in supporting documents, and in my USCIS

Part 7. Additional Information.

records, to other entities and persons where necessary for the

administration and enforcement of U.S. immigration laws.

Form I-131A 12/23/16 N

Page 2 of 5

Form I-131a - Application For Travel Document (Carrier Documentation) Page 2

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