LOCATION
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CURRENT VERSION
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PROPOSED
VERSION
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Page 1,
To
Be Completed by an Attorney
or Accredited Representative,
if any.
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Fill in box if G-28 is
attached…
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Select
the box if G-28 is attached…
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Page 1, Part 1.
Information About You
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3.
Alien
Registration Number
(A-Number)
1.a.
Family Name
(Last Name)
1.b.
Given Name
(First Name)
1.c.
Middle
Name
Mailing
Address
[sub-header]
2.a.
In Care of Name
2.b.
Street Number
and Name
2.c.
Apt.
Ste.
Flr.
2.d.
City or Town
2.e.
State
2.f.
Zip Code
2.g.
Postal Code
2.h.
Province
2.i.
Country
4.
Date of Birth
(mm/dd/yyyy)
5.
Country of Birth
6.
Country of
Citizenship
7.
U.S. Social
Security Number, if any
8.
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
(mm/dd/yyyy)
12.
Provide your
Form I-94, I-94W, or I-95 Arrival-Departure Record Number
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[Page 1]
1.
Alien
Registration Number
(A-Number)
2.
USCIS
ELIS Account Number (if
any)
Your
Full Name [new
sub-header]
3.a.
Family
Name (Last Name)
3.b.
Given
Name (First Name)
3.c.
Middle Name
U.S.
Mailing
Address [sub-header]
4.a.
In
Care Of Name
4.b.
Street
Number and Name
4.c.
Apt.
Ste.
Flr.
4.d.
City
or Town
4.e.
State
4.f.
ZIP
Code
[Deleted]
[Deleted]
[Deleted]
5.
Is
your current U.S. mailing address the same as your U.S. physical
address?
If
you answered "No" to Item
Number 5.,
provide your U.S. physical address in Item
Numbers 6.a. - 6.f.
U.S.
Physical Address
6.a.
In
Care Of Name
6.b.
Street
Number and Name
6.c.
Apt.
Ste.
Flr.
6.d.
City
or Town
6.e.
State
6.f.
ZIP
Code
Other
Information
7.
Date
of Birth
(mm/dd/yyyy)
8.
Country of
Birth
9.
Country
of Citizenship
10.
U.S.
Social Security Number (if
any)
Entry
Information
11.
Date
of Last
Entry
into
the United States (mm/dd/yyyy)
12.
Place
of
Last Entry
into
the United States (City
and State)
[Page
2]
13.
Current
Nonimmigrant Status
14.
Date
Status
Expires
(mm/dd/yyyy)
15.a.
Form
I-94, I-94W, or I-95 Arrival-Departure Record Number
15.b.
Passport
Number
15.c.
Travel
Document Number
15.d.
Country
of Issuance for Passport or Travel Document
15.e.
Expiration
Date for Passport or Travel Document
(mm/dd/yyyy)
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Page 2, Part 2. Reason
for Application
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Check
the box that best describes your reason for requesting an initial
or replacement document. (Check
only one)
…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.
1.e.
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…
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Select
the box that best describes your reason for requesting an initial
or replacement document. (Select
only
one
box)
…1.c.
I am applying
to replace my
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 my
Form I-95 because it has been mutilated. I have attached my
original Form I-95.
1.e.
I was not
issued Form I-94 when
I was admitted by CBP at a port-of-entry in the United States
(whether at a land border, airport, or seaport).
1.f.
I was issued
Form I-94, I-94W, or I-95 with incorrect information, and I am
requesting that
USCIS correct the
document. I have attached my original Form I-94, I-94W, or I-95…
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Page 2, Part 3.
Processing Information
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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.)
1.b.
USCIS Form
Number and Name
2.a.
Are you now in
removal proceeding? (If "Yes" complete number
2.b.)
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.
…4.
Class
of Admission
5.
Place
of Admission
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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
in Item
Number
1.b.
1.b.
USCIS
Form Number and Name
2.a.
Are
you now in removal proceedings?
If
"Yes" complete Item
Number
2.b.
2.b.
Provide
detailed information regarding the proceedings. If you need extra
space to
complete any item, attach a separate sheet of paper,
type
or print your
name and A-Number
(if any)
at the top of each sheet of paper;
indicate the Page
Number,
Part
Number, and
Item
Number to
which your answer refers, and date and sign each sheet.
…4.
Class
of Admission at Last
Entry into the United States
5.
Place
of Last
Entry into the United States (City
and State)
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Page 2, Part 4.
Signature of Applicant
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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.
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.
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[Page
3]
Part
4. Statement, Certification, Signature, and Contact Information
of the Applicant
NOTE:
Select the box for either Item
Number
1.a.
or
1.b.
If
applicable, select the box
for
Item
Number 2.
1.a.
I
can read and understand English, and have read and understand
every question and instruction on this form, as well as my answer
to every question.
1.b.
The
interpreter named below has read to me every question and
instruction on this form, as well as my answer to every question,
in
[language],
a
language in which I am fluent. I understand every question
and instruction on this form as translated to me by my
interpreter, and have provided true and correct responses in the
language indicated above.
2.
I
have requested the services of and consented to
[preparer],
who
is/
is
not
an
attorney or accredited
representative,
preparing this form for me.
Applicant
Certification
[new
sub-header]
I
certify, under penalty of perjury, that the
foregoing is true
and correct.
Copies of
documents submitted are exact photocopies of unaltered original
documents, and I understand that I may be required to submit
original documents to U.S. Citizenship and Immigration Services
(USCIS) at a later date. Furthermore, I authorize the release of
any information from my records that USCIS may need to determine
my eligibility for the benefit that I seek.
I
furthermore authorize release of information contained in this
form, in supporting documents, and in my USCIS records, to other
entities and persons where necessary for the administration of
U.S. immigration laws.
3.a.
Applicant's
Signature
3.b.
Date
of Signature
(mm/dd/yyyy)
Applicant's
Contact Information [sub-header]
4.
Applicant’s
Daytime
Telephone Number
5.
Applicant’s
Mobile
Telephone Number
6.
Applicant’s
E-mail
Address
[Deleted]
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New
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Page
3,
Part
5. Contact Information, Certification, and Signature of the
Interpreter
Interpreter's
Full Name
Provide
the following information concerning the interpreter:
1.a.
Interpreter's
Family Name (Last
Name)
1.b.
Interpreter's
Given Name (First
Name)
2.
Interpreter's
Business or Organization Name (if
any)
Interpreter's
Mailing Address
3.a.
Street
Number and Name
3.b.
Apt.
Ste.
Flr.
3.c.
City
or Town
3.d.
State
3.e.
ZIP
Code
3.f.
Province
3.g.
Postal
Code
3.h.
Country
Interpreter's
Contact Information [sub-header]
4.
Interpreter's
Daytime Phone Number
5.
Interpreter's
E-mail Address
Interpreter
Certification
I
certify that:
I
am fluent in English and [language]
which
is
the same language provided in Part
4., Item Number 1.b.;
I
have read to this applicant every question and instruction on this
form, as well as the answer to every question, in the language
provided in Part
4., Item Number 1.b.;
and
The
applicant has informed me that he or she understands every
instruction and question on the form, as well as the answer to
every question.
6.a.
Interpreter's
Signature
6.b.
Date
of Signature
(mm/dd/yyyy)
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Page 3, Part 5.
Signature of Person Preparing Form, If Other Than Applicant
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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.
…4.
Preparer's
Daytime Phone Number
Extension
5.
Preparer's
E-mail Address (if
any)
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)
…
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[Page
4]
Part
6.
Contact
Information, Declaration, and Signature
of the Person Preparing this Application,
If
Other than the
Applicant
[Deleted]
…Preparer's
Contact Information
4.
Preparer's
Daytime Telephone
Number
5.
Preparer's
Fax Number
6.
Preparer's
E-mail Address
7.a.
I
am not an attorney or accredited representative but have prepared
this form on behalf of the applicant and with the applicant's
consent.
7.b.
I
am an attorney or accredited representative and my representation
of the applicant in this case
(choose
one)
extends/does
not extend
beyond
the preparation of this form.
Preparer's
Declaration
By
my signature, I certify, swear, or affirm, under penalty of
perjury, that
I prepared this
form on behalf of, at
the request of,
and with the express consent of the
applicant.
I completed the form based only on responses the applicant
provided to me. After completing the form, I reviewed it and all
of the applicant's responses with the applicant, who agreed with
every answer provided for every question on the form and, when
required, supplied additional information to respond to a question
on the form.
8.a.
Preparer's
Signature
8.b.
Date
of Signature
(mm/dd/yyyy)
NOTE:
If
you need
extra
space to provide any additional information, attach
a separate
sheet of paper, type or print your name and A-Number, if any, at
the top of each sheet; indicate the Page Number, Part Number, and
Item Number to which your answer refers; and date and sign each
sheet.
8.a…
8.b…
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