OMB #1115-0079
U.S. Department of Justice
Application for Replacement/Initial
Immigration and Naturalization Service
Nonimmigrant Arrival - Departure Document
START HERE - Please Type or Print
FOR INS USE ONLY
Returned
Receipt
Part 1.
Information about you.
Family
Given
Middle
Date
Name
Name
Initial
Address - In
Date
care of
Resubmitted
Street Number
Apt.
and Name
#
Date
City
State
Zip
Code
Date
Date of Birth
Country
Reloc Sent
(Month/Day/Year)
of Birth
Social
A
Date
Security #
#
Date of Last Admission
I-94
Date
into U.S. (Month/Day/Year)
#
Reloc Rec’d
Current Nonimmigrant
Expires on
Status
(Month/Day/Year)
Date
Part 2.
Application type. (check one)
Date
" Applicant
"
a.
I am applying to replace my lost or stolen Form I-94.
Interviewed
"
b.
I am applying to replace my lost or stolen Form I-95.
"
c.
I am applying to replace Form I-94 it because it is mutilated. I have attached my original.
New I-94 Number
"
d.
I am applying to replace Form I-95 it because it is mutilated. I have attached my original.
"
e.
I was not issued a Form I-94 when I entered as a nonimmigrant, and am filing this
Action Block
application with an application for an extension of stay/change of status.
Part 3.
Processing Information.
Are you filing this application with any other petition or application?
"
"
No
Yes - Form #______
Are you now in exclusion or deportation proceedings?
"
"
No
Yes (Attach an explanation)
If you are unable to provide your original or a copy of your I-94, give the following information about
your last entry to the U.S.
To Be Completed by
Attorney or Representative , if any
Class of
Place of
Fill in box if G-28 is attached to represent
Admission
Admission
the applicant
VOLAG#
Part 4.
Signature.
Read the information on penalties in the instructions before
completing this section.
You must file this application while in the United
ATTY State License #
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 which the Immigration and Naturalization Service needs to determine eligibility for the
benefit I am seeking.
Signature
Date
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 Your Name
Date
Firm Name
and Address
Form I-102 (Rev. 06/13/95) N