Form I-102 - Application For Replacement/initial Nonimmigrant Arrival - Departure Document Page 5
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6OMB No. 1615-0079; Expires 06/30/07
I-102, Application for Replacement/Initial
Department of Homeland Security
Nonimmigrant Arrival - Departure Document
U.S. Citizenship and Immigration Services
START HERE - Please type or print in black ink.
For USCIS Use Only
Receipt
Returned
Part 1.
Information about you.
Family Name
Given Name
Middle Name
Date
Date
Address - In care of -
Resubmitted
Date
Street Number and Name
Apt./Suite #
In care of -
Date
Reloc Sent
City
State
Date
Zip/Postal Code
Country
Date of Birth (mm/dd/yyyy)
Date
Reloc Rec'd
Country of Birth
Country of Citizenship/Nationality
Date
Date
A # (if any)
U.S. Social Security # (if any)
Applicant
Interviewed
Date (mm/dd/yyyy) and Place of Last Admission
Current Nonimmigrant Status
on
New I-94 #
Status Expires on (mm/dd/yyyy)
I-94, I-94W or I-95 Arrival/Departure Document #
Remarks
Part 2.
Reason for application.
Check the box that best describes your reason for requesting a replacement document.
(Check one box.)
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.
Action Block
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
To Be Completed by
am requesting USCIS to correct the document. I have attached my original
Attorney or Representative, if any.
Form I-94, I-94W or Form I-95.
Fill in box if G-28 is attached
to represent the applicant.
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.
ATTY State License #
Form I-102 Form (Rev. 10/26/05)Y
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