Form I-102 - Application For Replacement/initial Nonimmigrant Arrival - Departure Document Page 6
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6Part 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:
Signature. Read the information on penalties in the instructions before completing this section.
Part 4.
You must file this application while in the United States.
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)
(
)
Part 5.
Signature of person preparing form, if other than above.
(Sign below.)
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)
E-Mail Address (if any)
Date (mm/dd/yyyy)
(
)
Form I-102 Form (Rev. 10/26/05)Y Page 2
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