Form DS-234 Special Immigrant Visa Biodata Form

U.S. Department of State

Bureau of Population, Refugees and Migration

OMB APPROVAL NO. 1405-xxxx
EXPIRES: xx/xx/xxxx
ESTIMATED BURDEN: 20 MIN.

SPECIAL IMMIGRANT VISA BIODATA FORM
Special immigrant visa applicants who qualify for and request resettlement assistance from the Department of State
must complete this form for each family member and submit it via email as a scanned attachment to the National Visa
Center at [email protected] .
A. CASE INFORMATION (To be completed by NVC)
NVC Case Number

Assigned Post

Post POC Information

B. CASE MEMBER
1. Case Size (Yourself plus family
members traveling with you)

2. Are you the principal applicant (PA)? 3. If not, what is your relationship to the
PA? (Husband, wife, son, daughter)
Yes

No

4. Name as it Appears on your Passport (Last, First, Middle)

5. Sex
Male

Female

6. Marital Status

7. Date of Birth (mm-dd-yyyy)

8. Place of Birth (City, Country)

9. Nationality

10. Ethnicity

11. Religion

12. Physical Address

13. Phone Number(s)

14. E-mail

15. Last Occupation/Skill

16. Education Level/Field of Study

17. Native Language

18. Other Language(s)

19. English Speaking Ability (Good,
Some, None)

DS-0234
xx-2012

20. Health Issues (Condition, Treatment, Pregnancy, Urgency, Comments)

Submit one copy of the Special Immigrant Visa Biodata form for each family member.
Send completed form(s) to the National Visa Center as an email attachment at [email protected] .

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C. CROSS REFERENCE
21. Do you have other immediate family members being processed on their own special immigrant visas?
Yes

No

22. If yes, do you wish to be resettled in the same city in the United States? If yes, please provide family member's
name, relationship to you and special immigrant visa case number.
Yes

No

D. U.S. TIES
23. Do you have family members or friends already residing in the United States? If yes, please provide family
information below. It may be possible to be resettled near them.
Yes
24. U.S. Relative's Name (Last, First, Middle)

No

25. Birth Date (mm-dd-yyyy) (If
known)

26. Address

27. Phone Number

28. Relationship to You

29. E-mail Address

E. COMMENTS

CONFIDENTIALITY STATEMENT AND PAPERWORK REDUCTION ACT STATEMENT
The information asked for on this form is requested in accordance with Section 222(f) of the Immigration and Nationality
Act, and is considered confidential. The information provided herein shall only be shared with State Department
personnel, officers of other federal agencies including the Department of Health and Human Services and the
Department of Homeland Security, and resettlement agency employees on a need to know basis. The U.S. Department
of State uses the facts you provide on this form to facilitate the provision of Resettlement and Placement benefits and to
assist in determining the location in the United States in which you will be resettled.
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time
required for searching existing data sources, gathering the necessary documentation, providing the information and/or
documents required, and reviewing the final collection. You do not have to supply this information unless this collection
displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or
recommendations for reducing it, please send them to: DOS/PRM, Office of Admissions, 2025 E Street, NW
Washington, DC 20522-0908.
DS-0234

Submit one copy of the Special Immigrant Visa Biodata form for each family member.
Send completed form(s) to the National Visa Center as an email attachment at [email protected] .

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