I-102 Form TOC

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0079

04/05/2019

Reason for Revision: Add collections for POE, Class of Admission, Name on I-94, explanation of error

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 10/31/2019

Edition Date 10/19/2017

Current Page Number and Section	Current Text	Proposed Text
Page 1, Part 1. Information About You	[Page 1] START HERE. Type or Print in black ink Part 1. Information About You 1. Alien Registration Number (A-Number) 2. USCIS Online Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name(First Name) 3.c. Middle Name U.S. Mailing Address 4.a. In Care Of Name 4.b. Street Number and Name 4.c. Apt. Ste. Flr. 4.d. City or Town 4.e. State 4.f. ZIP Code 5. Is your current U.S. mailing address the same as your U.S. physical address? Y/N If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.f. U.S. Physical Address 6.a. In Care Of Name 6.b. Street Number and Name 6.c. Apt. Ste. Flr. 6.d. City or Town 6.e. State 6.f. ZIP Code Other Information 7. Date of Birth (mm/dd/yyyy) 8. Country of Birth 9. Country of Citizenship 10. U.S. Social Security Number (if any) Entry Information 11. Date of Last Entry into the United States (mm/dd/yyyy) 12. Place of Last Entry into the United States (City and State) [Page 2] 13. Current Nonimmigrant Status 14. Date Status Expires (mm/dd/yyyy) 15.a. Form I-94, I-94W, or I-95 Arrival-Departure Record Number 15.b. Passport Number 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)	[Page 1] START HERE. Type or Print in black ink Part 1. Information About You 1. Alien Registration Number (A-Number) 2. USCIS Online Account Number (if any) Your Full Legal Name 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 names, and names from previous marriages. Provide evidence of any name changes. 4.a. Family Name (Last Name) 4.b. Given Name(First Name) 4.c. Middle Name U.S. Mailing Address 5.a. In Care Of Name 5.b. Street Number and Name 5.c. Apt. Ste. Flr. 5.d. City or Town 5.e. State 5.f. ZIP Code 6. Is your current U.S. mailing address the same as your U.S. physical address? Y/N 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 7.c. Apt. Ste. Flr. 7.d. City or Town 7.e. State 7.f. ZIP Code Other Information 8. Date of Birth (mm/dd/yyyy) 9. Country of Birth 10. Country of Citizenship 11. U.S. Social Security Number (if any) Entry Information 12. Date of Last Entry into the United States (mm/dd/yyyy) 13. Place of Last Entry into the United States (City and State) 14. Class of Admission at Last Entry Into the United States 15. Indicate the type of Port-of-Entry at which you last entered the United States: [] Land border [] Airport [] Seaport [Page 2] 16. Current Nonimmigrant Status 17. Date Status Expires (mm/dd/yyyy) 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 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) 19.c. Middle Name
Page 2, Part 2. Reason for Application	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. 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, 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.	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 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. 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. [fillable field] 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.
Page 2, Part 3. Processing Information	Part 3. Processing Information 1.a. Are you filing this application with any other petition or application? 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 2.a. Are you now in removal proceedings? If "Yes" complete Item Number 2.b. 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. If you are unable to provide the original of your Form I-94, I-94W, or I-95, provide the following information: NOTE: Provide your name exactly as it appears on Form I-94, I-94W, or I-95. 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)	Part 3. Processing Information 1.a. Are you filing this application with any other petition or application? If you answered "Yes" to Item 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 2.a. Are you now in removal proceedings? 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. [Deleted]
Page 3, Part 4. Statement, Certification, Signature, and Contact Information of the Applicant	[Page 3] Part 4. Statement, Certification, Signature, and Contact Information of the Applicant 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 have read and understand every question and instruction on this form, as well as my answer to every question. 1.b. The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in [fillable field], 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. I have requested the services of and consented to [fillable field], who is/is not an attorney or accredited representative, preparing this form for me. 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.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	[Page 3] Part 4. Applicant’s Statement, Contact Information, Certification, and 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. Applicant’s Statement 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. 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 [Fillable Field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 6., [Fillable field], prepared this application for me based only upon information I provided or authorized. 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) 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 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. 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. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) [Deleted] 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.
Page 3, Part 5. Contact Information, Certification, and Signature of the Interpreter	Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 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 [Page 4] Interpreter Certification I certify that: I am fluent in English and [fillable field], which is the same language provided in Part 4., Item Number 1.b.; 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 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. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)	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) 1.b. Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 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) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 4, Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant	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) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. 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. 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 8.b. Date of Signature (mm/dd/yyyy)\ 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.	Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 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. 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. 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) [Deleted]
Part 7. Additional Information	[New]	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. 1.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

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