Form I-102 Application for Replacement/Initial Nonimmigrant Arrival

OMB No. 1615-0079; Expires 07/30/08

I-102, Application for Replacement/Initial
Nonimmigrant Arrival - Departure Document

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.
Part 1.

For USCIS Use Only

Family Name

Receipt

Returned

Information about you.
Given Name

Middle Name

Date
Date
Resubmitted

Address - In care of Street Number and Name
In care of -

Apt./Suite #

City

Date
Date
Reloc Sent

State

Date
Zip/Postal Code

Country

Date of Birth (mm/dd/yyyy)

Country of Birth

Country of Citizenship/Nationality

A # (if any)

U.S. Social Security # (if any)

Date (mm/dd/yyyy) and Place of Last Admission

Current Nonimmigrant Status

Date
Reloc Rec'd
Date
Date
Applicant
Interviewed
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.

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
am requesting USCIS to correct the document. I have attached my original
Form I-94, I-94W, or Form I-95.

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.

Action Block

To Be Completed by
Attorney or Representative, if any.
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #

Form I-102 Form (Rev. 05/27/08)Y

Part 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:

Part 4. Signature.

(Read the information on penalties in the instructions before completing this section. 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 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. 05/27/08)Y Page 2