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

For
USCIS
Use
Only

OMB No. 1615-0079
Expires 10/31/2017

To Be Completed by an
Attorney or Accredited
Representative,
if any.
Select this box if Form
G-28 is attached to
represent the applicant.

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NOT FOR
PRODUCTION
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New I-94 Number

Attorney State
License Number

Remarks

► START HERE. Type or print in black ink

Part 1. Information About You

U.S. Physical Address

1.

6.a. In Care Of Name

Alien Registration Number (A-Number)
► A-

2.

USCIS Online Account Number (if any)
►

6.b. Street Number
and Name

6.c. Apt.

Your Full Name

Ste.

Flr.

6.d. City or Town

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

6.e. State

6.f.

ZIP Code

Other Information

3.c. Middle Name

U.S. Mailing Address

(mm/dd/yyyy) ►

7.

Date of Birth

8.

Country of Birth

9.

Country of Citizenship

10.

U.S. Social Security Number (if any)
►

4.a. In Care Of Name

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

Ste.

Flr.

4.d. City or Town

Entry Information
4.e. State
5.

4.f.

ZIP Code
11.

Date of Last Entry into the United States
(mm/dd/yyyy) ►

12.

Place of Last Entry into the United States (City and State)

Is your current U.S. mailing address the same as your
U.S. physical address?
Yes
No
If you answered "No" to Item Number 5., provide your
U.S. physical address in Item Numbers 6.a. - 6.f.

Form I-102 12/23/16 N

Page 1 of 4

Part 1. Information About You (continued)

Part 3. Processing Information

13.

Current Nonimmigrant Status

1.a. Are you filing this application with any other petition or
application?
Yes
No

14.

Date Status Expires
(mm/dd/yyyy) ►

15.a. Form I-94, I-94W, or I-95 Arrival-Departure Record Number

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

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15.b. Passport Number

2.a. Are you now in removal proceedings?

Yes

No

If "Yes" complete Item Number 2.b.

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) ►

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.

Part 2. Reason for Application

Select the box that best describes your reason for requesting an
initial or replacement document. (Select only one box)
1.a.

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 my Form I-94 or I-94W
because it was 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 was
mutilated. I have attached my original Form I-95.

If you are unable to provide the original of your Form I-94,
I-94W, or I-95, provide the following information:

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).

NOTE: Provide your name exactly as it appears on Form I-94,
I-94W, or I-95.

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.

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.

Form I-102 12/23/16 N

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
4.

Class of Admission at Last Entry into the United States

5.

Place of Last Entry into the United States (City and State)

Page 2 of 4

Part 4. Statement, Certification, Signature, and
Contact Information of the Applicant

Part 5. Contact Information, Certification, and
Signature of the Interpreter

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

Interpreter's Full Name

1.a.

Provide the following information concerning the interpreter:

1.b.

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

The interpreter named below has read to me every
question and instruction on this form, as well as my
answer to every question, in

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

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,

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.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3.a. Street Number
and Name

I have requested the services of and consented to

,

who is
is not
an attorney or accredited
representative, preparing this form for me.

2.

3.b. Apt.

Ste.

Flr.

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

3.e. ZIP Code

Applicant Certification

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.f.

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's E-mail Address

3.a. Applicant's Signature

3.b. Date of Signature (mm/dd/yyyy) ►

Applicant's Contact Information
4.

Applicant's Daytime Telephone Number

5.

Applicant's Mobile Telephone Number

6.

Applicant's E-mail Address

Form I-102 12/23/16 N

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Part 5. Contact Information, Certification, and
Signature of the Interpreter (continued)

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

Interpreter Certification
I certify that:

,which
I am fluent in English and
is the same language provided in Part 4., Item Number 1.b.;

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6.

Preparer's E-mail Address

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

7.a.

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.

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.

6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy) ►

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
Preparer's Full Name

Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

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

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

8.b. Date of Signature (mm/dd/yyyy) ►

2.

Preparer's Business or Organization Name

Preparer's Mailing Address

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.

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

3.g. Postal Code
3.h. Country

Form I-102 12/23/16 N

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