Form I-102 Application for Replacement/Initial Nonimmigrant Arrival

Application for Replacement/Initial Nonimmigrant
Arrival-Departure Document
Department of Homeland Security
U.S. Citizenship and Immigration Services

For
USCIS
Use
Only

OMB No. 1615-0079
Expires 10/31/2019

Action Block

Receipt

USCIS
Form I-102

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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New I-94 Number

Attorney State
License Number

Remarks

► START HERE. Type or print in black ink

Part 1. Information About You
1.

Alien Registration Number (A-Number)
► A-

2.

(USPS ZIP Code Lookup)

5.b. Street Number and Name

USCIS Online Account Number (if any)
►

5.c

Apt.

6.

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

3.c. Middle Name

Other Names Used (if any)

Provide all other names used. Include nicknames, aliases,
maiden name, and names from previous marriages. Provide
evidence of any name changes.

Flr.

5.d. City or Town
5.e. State

Your Full Legal Name

Ste.

5.f.

ZIP Code

Is your current U.S. mailing address the same as your
U.S. physical address?
Yes
No
If you answered "No" to Item Number 6., provide your
U.S. physical address in Item Numbers 7.a. - 7.f.

U.S. Physical Address

7.a. In Care Of Name

7.b. Street Number and Name

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

7.c.

4.c. Middle Name

7.e. State

U.S. Mailing Address

Other Information

5.a. In Care Of Name

8.

Date of Birth (mm/dd/yyyy)

9.

Country of Birth

10.

Country of Citizenship

Form I-102 10/19/17 N

Apt.

Ste.

Flr.

7.d. City or Town
7.f.

ZIP Code

Page 1 of 6

Part 1. Information About You (continued)

Part 2. Reason for Application

11.

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

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

1.a.

I am applying to replace my lost or stolen Form I-94
or Form 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 Form
I-94W because it was mutilated. I have attached my
original Form I-94 or Form 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.

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, Form I-94W, or Form I-95 by
USCIS with an error or incorrect information, and I
am requesting that USCIS correct the document. I
have attached my original Form I-94, Form I-94W, or
Form I-95.

Entry Information
12.

13.

14.

15.

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

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

Class of Admission at Last Entry Into the United States

Indicate the type of Port-of-Entry at which you last
entered the United States:
Land border
Airport
Seaport

16.

Current Nonimmigrant Status

17.

Date Status Expires (mm/dd/yyyy)

Provide an explanation of the error or incorrect
information entered on Form I-94, Form I-94W, or
Form I-95 at the time of issuance.

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

18.b. Passport Number

18.c. Travel Document Number

1.g.

18.d. Country of Issuance for Passport or Travel Document

18.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Provide your name exactly as it appears on Form I-94, Form
I-94W, or Form I-95. If the name on the form is different than
your current legal name as entered in Part 1., Item Numbers
3.a. - 3.c, provide evidence of the name change.
19.a. Family Name
(Last Name)
19.b. Given Name
(First Name)

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.

Part 3. Processing Information
1.a. Are you filing this application with any other petition or
application?
Yes
No
If you answered "Yes" to Items Number 1.a., 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

19.c. Middle Name

Form I-102 10/19/17 N

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Part 3. Processing Information (continued)
2.a. Are you now in removal proceedings?

Yes

Applicant's Certification
No

If you answered "Yes" to Item Number 2.a., complete
Item Number 2.b.
2.b. Provide detailed information regarding the proceedings.
If you need extra space to complete this section, use the
space provided in Part 7. Additional Information.

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.

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

Part 4. Applicant's Statement, Contact
Information, Certification, and Signature

Applicant's Signature

6.a. Applicant's Signature

NOTE: Read the Penalties section of the Form I-102
Instructions before completing this section.
You must file Form I-102 while in the United States.

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

Applicant's Statement

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.

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

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

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

Provide the following information about the interpreter.

Interpreter's Full Name

,

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

a language in which I am fluent, and I understood
everything.
2.

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

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

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

2.

Interpreter's Business or Organization Name (if any)

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Form I-102 10/19/17 N

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

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

Interpreter's Mailing Address

Provide the following information about the preparer.

3.a. Street Number and Name

Preparer's Full Name
3.b.

Apt.

Ste.

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

Flr.

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

Province

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

3.e. ZIP Code

2.

Preparer's Business or Organization Name (if any)

3.g. Postal Code
3.h. Country

Preparer's Mailing Address

3.a. Street Number and Name

Interpreter's Contact Information
4.

3.b.

Apt.

Ste.

Flr.

Interpreter's Daytime Telephone Number

3.c. City or Town

5.

3.d. State

Interpreter's Mobile Telephone Number (if any)

3.f.

6.

3.e. ZIP Code

Province

Interpreter's E-mail Address (if any)

3.g. Postal Code
3.h. Country

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.

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)

Interpreter's Signature
7.a. Interpreter's Signature

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

Form I-102 10/19/17 N

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Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
(continued)
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
does not extend
extends
beyond the preparation of this application.

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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, with this
application.

Preparer's Certification

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

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

Form I-102 10/19/17 N

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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 (if any)
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.

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-102 10/19/17 N

4.c. Item Number

7.a. Page Number

7.d.

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