Form I-131A Application for Travel (Carrier Documentation)

Application for Travel Document (Carrier Documentation)
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-131A
OMB No. 1615-New
Expires 00/00/20xx

Action Block

Receipt

For
USCIS
Document Issued

Use

DRAFT
Not For
Production
08/18/2016

Transportation Letter

Only

Boarding Foil

Document Hand Delivered
By:

Date:

(mm/dd/yyyy)

To be completed by an
attorney or accredited
representative (if any).

Select this box if
Form G-28 or
Form G-28I is
attached.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

4.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

If you answered "No" to Item Number 4., provide your U.S.
physical address in Item Numbers 5.a. - 5.e.

U.S. Physical Address

1.c. Middle Name
2.

Is your current mailing address the same as your U.S.
physical address?
Yes
No

Has your name changed since the issuance of your last
Permanent Resident Card (Form I-551)?
Yes
No

NOTE: If you answered "Yes" to Item Number 2., attach
evidence of your legal name change with this application.

Current Mailing Address

5.a. Street Number
and Name
5.b.

Apt.

Ste.

Flr.

5.c. City or Town
5.d. State

5.e. ZIP Code

3.a. In Care Of Name (if any)

Other Information
6.

3.b. Street Number
and Name
3.c.

Apt.

Alien Registration Number (A-Number)
► A-

Ste.

Flr.

7.

USCIS Online Account Number (if any)
►

3.d. City or Town
8.
3.e. State

3.f.

3.g. Province
3.h. Postal Code
3.i.

U.S. Social Security Number (if any)

ZIP Code

►
9.

Date of Birth (mm/dd/yyyy)

10.

Sex

Male

Female

Country

Form I-131A 10/16/13 N

Page 1 of 5

Part 1. Information About You (continued)

5.b. Date Issued (mm/dd/yyyy)

11.

Country of Birth

5.c. Disposition (attached, lost, etc.):

12.

Country of Citizenship or Nationality

Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
Part 2. Reason for Application
(Select only one box):

NOTE: Read the Penalties section of the Form 1-131A
Instructions before completing this part.

DRAFT
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08/18/2016

1.a.

My previous Permanent Resident Card has been lost,
stolen, or destroyed

1.b.

My previous Permanent Resident Card was issued but
never received

1.c.

My existing Permanent Resident Card has been
mutilated

1.d.

My existing Permanent Resident Card has already
expired

1.e.

Other (explain below):

2.

3.

1.a.

I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.

1.b.

The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in
,

2.

At my request, the preparer named in Part 6.,

Date Departed the United States (mm/dd/yyyy)

Applicant's Contact Information

Are you NOW, or were you EVER, in exclusion,
deportation, removal, or rescission proceedings?

Since you were granted permanent residence, have you
EVER filed Form I-407, Abandonment of Lawful
Permanent Resident Status, or otherwise been judged to
have abandoned your status?
Yes
No
If you answered "Yes" to Item Number 4., provide
details in the space provided in Part 7. Additional
Information.
No

If you answered "Yes" to Item Number 5.a., answer Item
Numbers 5.b. and 5.c. for the last document issued to you
and provide additional details in the space provided in
Part 7. Additional Information.

Form I-131A 10/16/13 N

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

No

If you answered "Yes" to Item Number 3., provide
details in the space provided in Part 7. Additional
Information.

5.a. Have you EVER been issued a Travel Document?
Yes

,

prepared this application for me based only upon
information I provided or authorized.

Date of Intended Travel to the United States
(mm/dd/yyyy)

Yes

4.

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.

a language in which I am fluent and I understood
everything.

Part 3. Processing Information
1.

Applicant's Statement

Applicant's Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
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Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and

I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.

6.a. Applicant's Signature

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

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2) All of this information was complete, true, and correct
at the time of filing.

Applicant's Signature

Interpreter's Mailing Address

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

6.b. Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.

Part 5. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and

,

which is the same language specified in Part 4., Item
Number 1.b., and I have read to this applicant in the identified
language every question and instruction on this application and
his or her answer to every question. The applicant informed me
that he or she understands every instruction, question, and
answer on the application, including the Applicant's
Certification, and has verified the accuracy of every answer.

Interpreter's Signature
1.b. Interpreter's Given Name (First Name)

2.

7.a. Interpreter's Signature

Interpreter's Business or Organization Name (if any)
7.b. Date of Signature (mm/dd/yyyy)

Form I-131A 10/16/13 N

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Part 6. Contact Information and Signature of the
Person Preparing this Application, if Other Than
the Applicant

Preparer's Statement
7.a.

I am not an attorney or accredited representative but
have prepared this application 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
extends
does not extend beyond the
preparation of this application.

Provide the following information about the preparer.

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)

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08/18/2016

1.b. Preparer's Given Name (First Name)

2.

NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the
Geographical Confines of the United States, with this
application.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

Preparer's Certification

3.a. Street Number
and Name
3.b.

Apt.

Ste.

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

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.

Preparer's Signature

8.a. Preparer's Signature

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Form I-131A 10/16/13 N

8.b. Date of Signature (mm/dd/yyyy)

Page 4 of 5

5.a. Page Number

Part 7. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.

1.c. Middle Name

► A-

A-Number

3.a. Page Number

5.d.

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1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

2.

5.b. Part Number 5.c. Item Number

3.b. Part Number

6.a. Page Number

6.b. Part Number 6.c. Item Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number

4.a. Page Number

4.b. Part Number 4.c. Item Number

7.b. Part Number 7.c. Item Number

7.d.

4.d.

Form I-131A 10/16/13 N

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