Form I-102 Application for Replacement/Initial Nonimmigrant Arrival

Application for Replacement/Initial Nonimmigrant
Arrival-Departure Document

USCIS
Form I-102

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

Receipt

New I-94 Number

Remarks
► Start Here. Type or Print in Black Ink

To Be Completed by an
Attorney/Representative,
if any.
Fill in box if G-28 is
attached to represent
the applicant.

DRAFT - Not For Production

For
USCIS
Use
Only

OMB No. 1615-0079
Expires 08/31/2012

Attorney State
License Number:

NOTE: Review instructions for detailed information on completing this form.

Part 1. Information About You
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Mailing Address
2.a. In Care of Name

Ste.

Flr.

2.d. City or Town
2.e. State

Country of Birth

6.

Country of Citizenship

7.

U.S. Social Security Number, if any

8.

2.b. Street Number
and Name
2.c. Apt.

5.

2.f.

Zip Code

2.g. Postal Code
2.h. Province
2.i.

Country

3.

Alien Registration Number (A-Number)

►

Date of last admission to the United States
(mm/dd/yyyy) ►

9.

Place of last admission to the United States

10.

What is your current Nonimmigrant Status?

11.

Status expires

12.

Provide your Form I-94, I-94W, or I-95 Arrival-Departure
Record Number

(mm/dd/yyyy) ►

►

► A4.

Date of Birth

Form I-102 10/13/11 N

(mm/dd/yyyy) ►

Page 1 of 3

Part 2. Reason for Application
Check the box that best describes your reason for requesting an
initial or replacement document. (Check only one)
I am applying to replace my lost or stolen Form I-94
or I-94W.

1.b.

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

1.c.

I am applying to replace Form I-94 or I-94W because
it has been mutilated. I have attached my original
Form I-94 or I-94W.

1.d.

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

Part 3. Processing Information
1.a. Are you filing this application with any other petition or
application? (If "Yes" provide the USCIS Form Number
and Name of the application or petition you are filing
concurrently in number 1.b.)
Yes
No
1.b. USCIS Form Number and Name
2.a. Are you now in removal proceeding? (If "Yes" complete
number 2.b.)
Yes
No
2.b. Provide detailed information regarding the proceedings. If
you need more space, use a separate sheet of paper. You
must include your name and Alien Registration Number
at the top of each sheet.

Part 4. Signature of Applicant
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.

I was not issued Form I-94 at admission, or I am
filing this application together with Form I-539,
Application to Extend/Change Nonimmigrant Status
for an extension of stay/change of status.

1.f.

I was issued Form I-94, I-94W, or 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 I-95.

DRAFT - Not For Production

1.a.

1.e.

1.g.

I was not issued 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.

If you are unable to provide the original of your Form I-94,
I-94W, or I-95, provide the following information:
NOTE: Provide your name exactly as it appears on Form I-94,
I-94W, or I-95.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
4.

Class of Admission

5.

Place of Admission

1.a. Signature of Applicant

1.b. Date of Signature (mm/dd/yyyy) ►
2.

Daytime Phone Number

(

)

-

NOTE: If you do not completely fill out this form or fail to
submit required documents listed in the instructions, your
application may be denied.

Form I-102 10/13/11 N

Page 2 of 3

Part 5. Signature of Person Preparing Form, If Other Than Applicant
NOTE: If you are an attorney or representative, you must
submit a completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, along with this
application.

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2.

Preparer's Business or Organization Name

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Postal Code

3.g. Province
3.h. Country

Form I-102 10/13/11 N

3.e. Zip Code

Preparer's Daytime Phone Number

(
5.

)

Extension

-

Preparer's E-mail Address (if any)

DRAFT - Not For Production

Provide the following information concerning the preparer:

4.

Declaration
To be completed by all preparers, including attorneys and
authorized representatives: I declare that I prepared this benefit
request at the request of the applicant, that it is based on all the
information of which I have knowledge, and that the
information is true to the best of my knowledge.
6.a. Signature
of Preparer
6.b. Date of Signature (mm/dd/yyyy) ►
NOTE: If you require more space to provide any additional
information, use a separate sheet of paper. You must include
your name and Alien Registration Number at the top of each
sheet.

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