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

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

USCIS
Form I-131A
OMB No. 1615-0135
Expires 08/31/2018

Action Block

Receipt

For

DRAFT
NOT FOR
REPRODUCTION
05/01/2018

USCIS

Document Issued

Use

Transportation Letter

Only

Boarding Foil

Document Hand Delivered
By:

Date:

(mm/dd/yyyy)

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

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

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

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

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

Current Mailing Address

(USPS ZIP Code Lookup)

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 12/23/16 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, Declaration, Certification, and
Signature

DRAFT
NOT FOR
REPRODUCTION
05/01/2018

Part 2. Reason for Application

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

Select only one box.
1.a.
1.b.
1.c.
1.d.
1.e.

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

Applicant's Statement

My previous Permanent Resident Card was issued but
never received.

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

My existing Permanent Resident Card has been
mutilated.

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

My existing Permanent Resident Card has already
expired.
Other (explain below).

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

Part 3. Processing Information
1.

2.

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

2.

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

3.

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

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 4., provide details
in the space provided in Part 7. Additional Information.
5.a. Have you EVER been issued a Travel Document?
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 12/23/16 N

,

Applicant's Contact Information

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

Yes

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

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

If you answered "Yes" to Item Number 3., provide
details in the space provided in Part 7. Additional
Information.
4.

,

Applicant's Declaration and 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 that 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 law.
Page 2 of 5

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

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.

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

Applicant's Signature

Interpreter's Certification

6.a. Applicant's Signature

I certify, under penalty of perjury, that:

DRAFT
NOT FOR
REPRODUCTION
05/01/2018
I am fluent in English and

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.

,

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 Declaration and Certification, and has
verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

Interpreter's Full Name

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

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

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

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

2.

Interpreter's Business or Organization Name (if any)

Provide the following information about the preparer.

Interpreter's Mailing Address

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

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

Apt.

Preparer's Full Name

Ste.

Flr.

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

3.c. City or Town
2.
3.d. State
3.f.

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-131A 12/23/16 N

Page 3 of 5

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

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 Declaration and 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.

DRAFT
NOT FOR
REPRODUCTION
05/01/2018
Apt.

Ste.

Flr.

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

Preparer's Certification

Preparer's Signature

3.e. ZIP Code

8.a. Preparer's Signature

Province

3.g. Postal Code

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

3.h. Country

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)

Preparer's Statement
7.a.

7.b.

I am not an attorney or accredited representative
but have prepared this application on behalf of the
applicant and with the applicant's consent.
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.

NOTE: If you are an attorney or accredited
representative, you may need 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.

Form I-131A 12/23/16 N

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.

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

5.d.

DRAFT
NOT FOR
REPRODUCTION
05/01/2018

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

1.c. Middle Name
2.

► A-

A-Number

3.a. Page 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 12/23/16 N

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