I-102 Instructions TOC

TABLE OF CHANGES - Instructions

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

OMB No: 1615-0079

09/16/2014

Reason for Change: U.S. Customs and Border Protection (CBP) is automating Form I-94 Arrival-Departure Records to streamline passenger processing. CBP enters data admission information into the Treasury Enforcement Communications System (TECS) and the Arrival and Departure Information System (ADIS). Form I-94 admission information is used by U.S. Citizenship and Immigration Services (USCIS) to search TECS and ADIS in order to verify applicant, petitioner or beneficiary status in the United States at the time an application or petition is filed. The instructions are being revised to clarify when this form should be used versus when the individual should visit the CBP Web site in order to obtain an initial or replacement Form I-94. The instructions also explain the new data fields on the form requesting foreign passport information. The changes being proposed will be made to reflect the I-94 requirements. In addition, ELIS Account Number information has been incorporated into the instructions, to correlate with the new data collection on the form. Finally, new language has been included to correlate with the revisions made to the Applicant’s and Preparer’s sections of the form, and the new Interpreter section of the form. All revisions are being made to the latest version of the form, dated 2/17/13 N.

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1, When Should I Use This Form?	You may file a Form I-102 if you: 1. Were admitted at a port of entry in the United States by air, sea port, or arriving by land/border crossing and you were not issued an initial Form I-94, I-94W, or I-95 or need to replace your lost, stolen, or mutilated Form I-94, I-94W, or I-95; NOTE: If you were admitted at an air or sea port of entry and issued an electronic Form I-94, you should go to the U.S. Customs and Border Patrol (CBP) Web site at www.cbp.gov/I94 in order to obtain an initial or replacement paper version of Form I-94. Follow the instructions you received from CBP on how to do this. You may print-out a paper version of your Form I-94 from this Web site. CBP does not charge a fee for this service. If you are unable to obtain your Form I-94 from the CBP Web site or do not want to use the CBP Web site, you may use this form (Form I-102) to obtain a paper Form I-94. However, you must pay the Form I-102 filing fee when submitting this form to USCIS. 2. Would like to replace a lost, stolen, or mutilated Form I-94W or receive an initial Form I-94W, but only if you were admitted at a land border port of entry, or you were admitted at an air or sea port of entry on or before June 28, 2010…	Page 1, When Should I Use This Form? You may file a Form I-102 if you: 1. Were admitted at a port-of-entry (POE) in the United States (whether at a land border, an airport, or a seaport) and: A. You were not issued an initial Form I-94, I-94W, or I-95; or B. You need to replace your lost, stolen, or mutilated Form I-94, I-94W, or I-95. NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have been issued an electronic Form I-94 by CBP, instead of a paper Form I-94.  You may visit the CBP Web site at www.cbp.gov/i94 to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service.  Some travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013 with a passport or travel document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form I-94 from the CBP Web site without charge.  If your Form I-94 cannot be obtained from the CBP Web site, it may be obtained by filing Form I-102 with USCIS.  USCIS does charge a fee for this service. 2. Would like to replace a lost, stolen, or mutilated Form I-94W or receive an initial Form I-94W, but only if you were admitted at a POE at a land border, or you were admitted at a POE at an airport or seaport on or before June 28, 2010...
Page 1 -2, General Instructions	[Page 1] Each application must be properly signed and accompanied by the appropriate fee. (See "What Is the Filing Fee?" section of these instructions.) A photocopy of a signed application or typewritten name in place of a signature is not acceptable. If you are under 14 years of age, your parent or legal guardian may sign the application on your behalf. Evidence. You must submit all required initial evidence along with all the supporting documentation with your application at the time of filing. Copies. Unless specifically required that an original document be filed with an application or petition, an ordinary legible photocopy may be submitted. Original documents submitted when not required may remain a part of the record, and will not be automatically returned to you. Translations. Any document containing a foreign language submitted to USCIS shall be accompanied by a full English language translation which the translator has certified as complete and accurate, and by the translator's certification that he or she is competent to translate from the foreign language into English. How to Fill Out Form I-102 A separate Form I-102 must be filed for each person seeking the immigration benefit. 1. Type or print legibly in black ink. 2. If extra space is needed to complete any item, attach a continuation sheet, write your name and Alien Registration Number (A-Number) (if any), at the top of each sheet of paper, indicate the Part and item number to which your answer refers, and date and sign each sheet. 3. Answer all questions fully and accurately. If an item is not applicable or the answer is none, leave the answer blank.	Page 1, General Instructions USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which can be downloaded for free at http://get.adobe.com/reader/. Each application must be properly signed and filed. A photocopy of a signed application or a typewritten name in place of a signature is not acceptable. If you are under 14 years of age, your parent or legal guardian may sign the application on your behalf Each application must be accompanied by the appropriate filing fee. (See the What Is the Filing Fee section of these instructions for more information.) Evidence. You must submit all required initial evidence and supporting documentation with your application at the time of filing. If you are electronically filing this application, you must follow the instructions provided on the USCIS Electronic Immigration System (USCIS ELIS) Web site, www.uscis.gov/uscis-elis. Copies. You may submit a legible photocopy of the documents requested, unless the instructions specifically state that you must submit an original document. Original documents submitted when not required may remain a part of the record, and USCIS will not automatically return them to you. Translations. Any document you submit to USCIS with information in a foreign language must have a full English translation. The translator must certify that the English language translation is complete and accurate, and that he or she is competent to translate from the foreign language into English. How to Fill Out Form I-102 You must file a separate Form I-102 for each person seeking the immigration benefit. 1. Type or print legibly in black ink. 2. If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and Alien Registration Number (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. 3. Answer all questions fully and accurately. If an item is not applicable or the answer is "none," type or print "N/A," unless otherwise directed.
Page 2-4, Specific Instructions	[Page 2] Form I-102 is divided into Parts 1 through 5. The following information should help you fill out the form. Part 1. Information About You [See Item Number 3. below] 1.a. - 1.c. Your Full Name Provide your legal name. If you have two last names, include both and use a hyphen (-) between the names, if appropriate. 2.a. - 2.i. Mailing Address List your complete mailing address in the spaces provided. If your mail will be sent to someone other than yourself, please include an "In Care Of Name" as part of your mailing address. 3. Alien Registration Number (A-Number) This is your immigration file number. If you do not have an Alien Registration Number or do not know it, leave this blank. 4. Date of Birth Provide your date of birth (mm/dd/yyyy) in the space provided as it is shown on your birth certificate or other government-issued identity document. 5. - 6. Country of Birth and Country of Citizenship Provide the name of the country of your birth and the name of the country of your citizenship. The name of the country should be the current name of the country. 7. U.S. Social Security Number Provide your Social Security Number. If you do not have a U.S. Social Security Number, leave this blank. 8. - 9. Date and Place of Last Admission to the United States Provide the date (mm/dd/yyyy) and location of your last actual entry into the United States. 10. What is your current Nonimmigrant Status? Provide your current status. If you were granted a change of status, provide a copy of the approval notice noting the change. 11. Status Expires Provide the ending date of your authorized stay in the United States. 12. Form I-94, I-94W, or I-95 Arrival-Departure Number Provide your Form I-94, I-94W, or I-95 Arrival-Departure Number, if you have one. Otherwise, leave it blank. Part 2. Reason for Application The following is a brief description of eligibility categories. Check the box in Part 2 of Form I-102 that matches your reason for filing. After determining which category best applies, you must submit evidence that proves eligibility. Each category has specific evidence requirements. See section entitled "Submit Your Application," for information on what evidence is required. You should use Form I-102 to: 1. Replace your lost, stolen, or mutilated Form I-94, I-94W, or I-95; NOTE: If you were issued an electronic Form I-94 by CBP at an air or sea port of entry, you may not need to file Form I-102. Instead, you may be able to obtain a replacement Form I-94 by going to the CBP Web site at www.cbp.gov/I94. No fee is charged for this service. See the NOTE in the section entitled, “When Should I Use This Form” for more information. 2. Receive an initial Form I-94 or I-94W if you were not issued one at admission, or you are filing this Form I-102 with Form I-539, Application to Extend/Change Nonimmigrant Status. NOTE: If you were issued an electronic Form I-94 by CBP at an air or sea port of entry, you may not need to file Form I-102. Instead, you may be able to obtain an initial Form I-94 by going to the CBP Web site at www.cbp.gov/I94. No fee is charged for this service. See the NOTE in the section entitled, “When Should I Use This Form” for more information. 3. Receive a corrected Form I-94, I-94W, or I-95 if you were issued one by USCIS with incorrect information. NOTE: If CBP issued you Form I-94, I-94W, or I-95 with incorrect information (for example: misspelled name, incorrect date of birth, visa classification, or date of admission), you should not file Form I-102. You will need to go to the nearest CBP port of entry (POE) or the nearest CBP deferred inspection office (DIO), in person, to have the information corrected. For locations and hours of operation visit the CBP's Web site at www.cbp.gov. …c. Nonimmigrant member of the Partnership for Peace military program under the Status of Forces Agreement (SOFA). Part 3. Processing Information 1.a. - 5. Provide all information requested in the spaces provided. Part 4. Signature of Applicant As the applicant, you must sign, date and provide a daytime telephone number on the space provided on the application. If you do not sign the form, it will be rejected as incomplete. Part 5. Signature of Person Preparing Form, If Other than Applicant If you, the applicant, did not fill out Form I-102, the preparer of the application must also sign, date and provide his or her name, address, daytime telephone number, and e-mail address in the spaces provided. Part 6. Declaration, Signature and Contact Information of the Person Preparing This Application, If Other than Applicant If you, the applicant, did not fill out Form I-102, the preparer of the application must also sign, date, and provide his or her name, address, daytime telephone number, fax number, and e-mail address in the spaces provided. The preparer must also select the appropriate boxes indicating whether he or she is or is not an attorney or accredited representative, and whether his or her representation of you extends beyond the preparation of this form. … Submit Your Application… …b. Lost or Stolen Form I-94, I-94W, or I-95. If you are applying to replace a lost or stolen Form I-94, I-94W, or I-95, submit a copy of the original or submit a copy of the biographic page from your passport and a copy of the page indicating admission as claimed, or other evidence of your admission. If you are unable to provide this evidence, submit a full explanation stating why you cannot give any of the above evidence, along with a copy of evidence of your identity and copies of any evidence in your possession to substantiate your claim. If your Form I-94, I-94W, or I-95 was stolen, submit a copy of the police report relating to the theft… d. First Form I-94. If you were not issued Form I-94 at admission and have not since been issued Form I-94, but now require Form I-94 for another application you are filing, submit a copy of any evidence in your possession to substantiate your claimed admission. e. Nonimmigrant Military Member… f. Correct Inaccurate Information. If you want USCIS to correct inaccurate information on your Form I-94, I-94W, or I-95, attach your Form I-94, I-94W, or I-95 to your application. If you check box "1.f." in Part 2, Reason for Application, attach a statement dated and signed by you, citing specifically what information on your Form I-94, I-94W, or I-95 requires correction. You must also attach evidence verifying the validity of the information submitted for correction purposes. g. Not Issued Form I-94/Extension-Status Change. If you were not issued Form I-94 at admission or are filing this application with a Form I-539, Application to Extend/Change Nonimmigrant Status. Check box "1.e." in Part 2, Reason for Application, and file this form in accordance with Form I-539 filing instructions.	Page 2, Specific Instructions Form I-102 is divided into Parts 1. - 6. The following information should help you fill out the form. Part 1. Information About You Item Number 1. Alien Registration Number (A-Number). This is your immigration file number.  If you do not have an Alien Registration Number or do not know it, leave this blank. Item Number 2. USCIS ELIS Account Number (if any). If you previously filed any USCIS form using USCIS ELIS, provide the USCIS ELIS Account Number you were issued. The USCIS ELIS Account Number is not the same as an A-Number. If you were issued a USCIS ELIS Account Number, enter it in the space provided. Item Numbers 3.a. - 3.c. Your Full Name. Provide your legal name.  If you have two last names, include both and use a hyphen (-) between the names, if appropriate. Item Numbers 4.a. - 5. U.S. Mailing Address. Provide your complete U.S. mailing address in the spaces provided. If your mail is sent to someone other than yourself, include an "In Care Of Name" as part of your mailing address. Item Numbers 6.a. - 6.f. U.S. Physical Address. Provide your physical address if this address is different from your U.S. mailing address. [See Item Number 1.] Item Number 7. Date of Birth. Provide your date of birth (mm/dd/yyyy) in the space provided as it is shown on your birth certificate or other government-issued identity document. Item Numbers 8. - 9. Country of Birth and Country of Citizenship. Provide the name of the country of your birth and the name of the country of your citizenship. Use the current names of the country of your birth and country of your citizenship. Item Number 10. U.S. Social Security Number. Provide your U.S. Social Security Number. If you do not have a U.S. Social Security Number, leave this field blank. Item Numbers 11. - 12. Date and Place of Last Entry into the United States. Provide the date (mm/dd/yyyy) and location of your last actual entry into the United States. Item Number 13. Current Nonimmigrant Status. Provide your current status. If you were granted a change of status, provide a copy of the approval notice noting the change. Item Number 14. Date Status Expires. Provide the date (mm/dd/yyyy) your authorized period of stay in the United States expires or expired. Item Number 15.a. Form I-94, I-94W, or I-95 Arrival-Departure Number. Provide your Form I-94, I-94W, or I-95 Arrival-Departure Number, if you have one. Otherwise, leave this field blank. The I-94 number is on the Form I-94 Arrival-Departure Record, which may be noted as the Departure Number on some versions.  If CBP did not provide you with a Form I-94 upon arrival/admission to the United States, you may print out a paper version of the Form I-94 from the CBP Web site at www.cbp.gov/i94 according to the instructions provided by CBP at the time of admission. Item Number 15.b. Passport Number. Enter the passport number of the passport you used at your last entry into the United States, even if that passport has expired. Skip Item Number 15.c. if you provided your passport number in this box. Item Number 15.c. Travel Document Number. If you do not have your passport number, enter the travel document number of the travel document you used at your last entry into the United States, even if that travel document has expired. Item Number 15.d. Country of Issuance for Passport or Travel Document. Enter the country that issued the passport or travel document number you provided in Item Numbers 15.b. or 15.c. Item Number 15.e. Expiration Date for Passport or Travel Document. Enter the expiration date (mm/dd/yyyy) of the passport or travel document number you provided in Item Numbers 15.b. or 15.c. Part 2. Reason for Application The following is a brief description of eligibility categories. Select only one box in Part 2. of Form I-102 that matches your reason for filing. After determining which category best applies, you must submit evidence that proves eligibility. Each category has specific evidence requirements. See the Submit Your Application section in these instructions for information on what evidence is required. You should use Form I-102 to: 1. Replace your lost, stolen, or mutilated Form I-94, I-94W, or I-95. Select box "1.a.," "1.b.," "1.c.," or "1.d." in Part 2. NOTE: If you were issued an electronic Form I-94 by CBP at a POE at an airport or seaport, you may not need to file Form I-102 to receive your Form I-94 in paper format. Instead, you may be able to obtain your Form I-94 in paper format by going to the CBP Web site at www.cbp.gov/I94 and following the instructions on the Web site. No fee is charged for this service. See the NOTE in the When Should I Use This Form section of these instructions for more information. 2. Receive an initial Form I-94 or I-94W if you were admitted to the United States at a POE (whether at a land border, airport, or seaport) and you were not issued an initial Form I-94 or I-94W at admission. Select box “1.e.” in Part 2. NOTE: If you were issued an electronic Form I-94 by CBP at a POE at an airport or seaport, you may not need to file Form I-102 to receive your Form I-94 in paper format. Instead, you may be able to obtain your Form I-94 in paper format by going to the CBP Web site at www.cbp.gov/I94 and following the instructions on the Web site. No fee is charged for this service. See the NOTE in the When Should I Use This Form section of these instructions for more information. 3. Receive a corrected Form I-94, I-94W, or I-95 if you were issued one by USCIS with incorrect information. Select box "1.f." in Part 2. NOTE: If CBP issued you Form I-94, I-94W, or I-95 with incorrect information (for example: misspelled name, incorrect date of birth, visa classification, or date of admission), you should not file Form I-102. You will need to go to the nearest CBP POE or the nearest CBP deferred inspection office, in person, to have the information corrected. For locations and hours of operation visit the CBP's Web site at www.cbp.gov/xp/cgov/toolbox/contacts/. …C. Nonimmigrant member of the Partnership for Peace military program under the Status of Forces Agreement (SOFA). Select box “1.g.” in Part 2. Part 3. Processing Information Item Numbers 1.a. - 5. Provide all information requested in the spaces provided. Part 4. Statement, Certification, Signature and Contact Information of the Applicant Select the box that indicates if you filled out this form or if someone interpreted this form for you.  If applicable, select the box that indicates if someone filled out this form for you.  Every application must contain the original signature of the applicant.  A photocopy of a signed application or a typewritten name in place of a signature is not acceptable.  If you are under 14 years of age, your parent or legal guardian may sign the application on your behalf.  Sign and date the form and provide your daytime telephone number, mobile telephone number, and e-mail address. Part 5. Contact Information, Certification, and Signature of Interpreter If you used an interpreter to read the instructions and complete the questions on this form, the interpreter must fill out this section, provide the name of his or her business/organization, the business/organization’s address, his or her daytime telephone number, and his or her e-mail address. The interpreter must also sign and date the form. Part 6. Contact Information, Declaration, and Signature of the Person Preparing This Application, If Other than Applicant This section must contain the original signature of the person who completed this form, if other than the person named in Part 4. If the person who completed this form is associated with a business or organization, the preparer should provide the name of his or her business/organization name and address. If the person completing this form is an attorney or accredited representative, he or she must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with this application. … Submit Your Application… …B. Lost or Stolen Form I-94, I-94W, or I-95. If you are applying to replace a lost or stolen Form I-94, I-94W, or I-95, submit a copy of the biographic page from your passport and a copy of the page indicating admission as claimed, or other evidence of your admission.  If you are unable to provide this evidence, submit a full explanation stating why you cannot give any of the above evidence, along with a copy of evidence of your identity and copies of any evidence in your possession to substantiate your claim.  If your Form I-94, I-94W, or I-95 was stolen, submit a copy of the police report relating to the theft, if available. If a police report is unavailable or was not made, submit an explanation describing the circumstances of the theft and why the police report is unavailable or was not made… D. Not Issued Form I-94 at Admission. If you were not issued Form I-94 at admission to the United States at a POE (whether at a land border, airport, or seaport), attach a copy of your passport with the admission stamp issued by CBP. If you were issued an electronic Form I-94 by CBP upon your admission at a POE at an airport or seaport, you may be able to obtain your Form I-94 in paper format by accessing the CBP Web site at www.cbp.gov/I94. This service is free. See the NOTE in the When Should I Use This Form section of these instructions. (See F. below.) E. Correct Inaccurate Information. If you want USCIS to correct inaccurate information that USCIS issued on your Form I-94, I-94W, or I-95, attach your Form I-94, I-94W, or I-95 to your application. Also attach a statement dated and signed by you, citing specifically what information on your Form I-94, I-94W, or I-95 requires correction. You must also attach evidence verifying the validity of the information submitted for correction purposes. F. Nonimmigrant Military Member… [Deleted]
Page 4-5, What Is the Filing Fee?	…3. You do not need to pay the fee if you are a nonimmigrant military member in the U.S. Armed Forces or you are participating in a NATO or Partnership for Peace military program under the SOFA, and you are requesting an initial Form I-94. Check Box "1.g." in Part 2, Reason for Application, if this applies to you. How To Check If the Fees Are Correct … 2. Telephone the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TDD (hearing impaired) call: 1-800-767-1833.	Page 5, What Is the Filing Fee? …3. You do not need to pay the fee if you are a nonimmigrant military member in the U.S. Armed Forces or you are participating in a NATO or Partnership for Peace military program under the SOFA, and you are requesting an initial Form I-94. Select box "1.g." in Part 2. if this applies to you. How To Check If the Fees Are Correct … 2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TDD (deaf or hard of hearing) call: 1-800-767-1833.
Page 5, Where to File?	Please see our Web site at www.uscis.gov/I-102 or call our National Customer Service Center at 1-800-375-5283 for the most current information about where to file this benefit request. For TDD (hearing impaired) call: 1-800-767-1833.	Page 6, Where To File? Please see our Web site at www.uscis.gov/I-102 or call our National Customer Service Center at 1-800-375-5283 for the most current information about where to file this benefit request. For TDD (deaf or hard of hearing) call: 1-800-767-1833.
Page 5, Address Changes	If you changed your address, you must inform USCIS of your new address. For information on filing a change of address go to the USCIS Web site at www.uscis.gov/addresschange or contact the National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833…	Page 6, Address Changes You must inform USCIS if you change your address. For information on filing a change of address go to the USCIS Web site at www.uscis.gov/addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TDD (deaf or hard of hearing) call: 1-800-767-1833 If you are filing this form in USCIS ELIS, you must change your address in USCIS ELIS by logging into your user account and updating your Account Profile…
Page 5-6, Processing Information	Initial Processing Once Form I-102 has been accepted, it will be checked for completeness, including submission of any required initial evidence. If you do not completely fill out the form…and we may deny your Form I-102. Requests for More Information or Interview We may request more information or evidence, or we may…..We will return these originals when they are no longer required. …Decision You will be notified in writing of the decision on your application. If the application is approved, a new Form I-94, Form I-94W or Form I-95 will be issued to you.	Page 7, Processing Information Initial Processing Once USCIS accepts your application, we will check it for completeness, including any required initial evidence. If you do not completely fill out the form…and we may deny your application. Requests for More Information or Interview We may request more information or evidence from you, or we may…..We will return these originals when they are no longer needed. …Decision The decision on Form I-102 involves a determination of whether you have established eligibility for the requested benefit. USCIS will notify you of the decision in writing. If the application is approved, USCIS will issue you a new Form I-94, I-94W, or I-95.
Page 6, USCIS Forms and Information	To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USICS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling our USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833. As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through the USCIS Internet-based system, InfoPass. To access the system, visit the USCIS Web site. Use the InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen.	Page 7, USCIS Forms and Information To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order USCIS forms by calling our toll-free number at 1-800-870-3676.  You may also obtain forms and information by calling our USCIS National Customer Service Center at 1-800-375-5283. For TDD (deaf or hard of hearing) call: 1-800-767-1833. As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through the USCIS Internet-based system, InfoPass. To access the system, visit the USCIS Web site at infopass.uscis.gov/. Use the InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen.
Page 6, USCIS Privacy Act Statement	AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act, section 101, et seq. PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have established eligibility for the immigration benefit for which you are filing. The information you provide will be used to grant or deny the benefit sought. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of your form. ROUTINE USES: The information you provide on this form may be shared with other Federal, State, local, and foreign government agencies and authorized organizations following approved routine uses described in the associated published system of records notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001 - Alien File, Index, and National File Tracking System of Records, which can be found at www.dhs.gov/privacy]. The information may also be made available, as appropriate, for law enforcement purposes or in the interest of national security.	Page 7, USCIS Privacy Act Statement AUTHORITIES: The information requested on this form, and the associated evidence, is collected pursuant to section 212(d)(5) of the Immigration and Nationality Act and 8 CFR section 235.1. PURPOSE: The primary purpose for providing the requested information on this form is to request for a new or replacement Form I-94 or I-95 Nonimmigrant Arrival-Departure Document. USCIS will use the information you provide to issue or deny the benefit sought. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of your form. ROUTINE USES: USCIS may share the information you provide on this form may be shared with other Federal, state, local, and foreign government agencies and authorized organizations in accordance with approved routine uses, as described in the associated published system of records notices [DHS-USCIS-007 - Benefits Information System and DHS/USCIS-015 - Electronic Immigration System-2 Account and Case Management System of Records, which you can find at www.dhs.gov/privacy]. USCIS may also make the information available, as appropriate, for law enforcement purposes or in the interest of national security.
Page 6, Paperwork Reduction Act	An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 25 minutes per response, including the time for reviewing instructions and completing and submitting the form…	Page 7, Paperwork Reduction Act An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 45 minutes per response (paper-format), including the time for reviewing instructions and completing and submitting the form; and 35 minutes for the electronic submission of this type of request…

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