I-102: Application For Replacement/initial Nonimmigrant Arrival printable pdf download

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

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

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

I am applying to replace my lost or stolen Form I-94.

Interviewed

I am applying to replace my lost or stolen Form I-95.

I am applying to replace Form I-94 it because it is mutilated. I have attached my original.

New I-94 Number

I am applying to replace Form I-95 it because it is mutilated. I have attached my original.

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?

Yes - Form #______

Are you now in exclusion or deportation proceedings?

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

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