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Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-131A, we

will deny your Form I-131A and may deny any other immigration benefit. In addition, you will face severe penalties

provided by law and may be subject to criminal prosecution.

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this benefit form, and the associated evidence, is collected pursuant to 8

U.S.C. sections 1103, 1158, 1182, 1203 and 1204.

PURPOSE: The sole purpose for providing the requested information on this benefit form is to apply for a Carrier

Evidence document with either USCIS or the Department of State within one year of your departure from the United

States, which will allow you to board a vessel or aircraft, travel to the United States, and present yourself at a U.S. port-of-

entry for inspection as a returning lawful permanent resident. This information is used to grant or deny your benefit.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and

any requested evidence, may delay a final decision or result in denial of your benefit request.

ROUTINE USES: The information you provide on this benefit application may be shared with other federal, state, local,

and foreign government agencies and authorized organizations in accordance with approved routine uses, as described

in the associated published system of records notices [DHS-USCIS-001 - Alien File, Index, and National File Tracking

System of Records, DHS-USCIS-007 - Benefits Information System, and STATE-39 Visa Records, which can be found

and , respectively]. The information may also be made available, as

appropriate for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection

of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The

public reporting burden for this collection of information is estimated at 55 minutes per response, including the time

for reviewing instructions, gathering the required documentation and information, completing the application, attaching

necessary documentation, and submitting the application. Send comments regarding this burden estimate or any

other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and

Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW,

Washington, DC 20529-2140; OMB No. 1615-0135. Do not mail your completed Form I-131A to this address.

Form I-131A Instructions 12/23/16 N

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Instructions For Form I-131a - Application For Travel Document (Carrier Documentation) Page 6