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

Application for Carrier Documentation

USCIS
Form I-131A

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0135
Expires 02/28/2021

Action Block

Receipt

For
USCIS
Use
Only

DRAFT
Not for
Production
04/06/2020

Document Issued

Transportation Letter

Boarding Foil

Document Hand Delivered
By:

Date:

(mm/dd/yyyy)

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

Select this box if
you attach Form
G-28 or Form
G-28I.

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

Current Mailing Address

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

3.a. In Care Of Name (if any)

1.c. Middle Name
2.

Have you changed your name since receiving your last
Form I-551, Permanent Resident Card, Form I-512 or
I-512L, Advanced Parole Document, or Form I-766,
Employment Authorization Document (with travel
endorsement)?
Yes
No

( USPS ZIP Code Lookup)

3.b. Street Number
and Name
3.c.

Apt.

Ste.

Flr.

3.d. City or Town
3.e. State

3.f.

ZIP Code

3.g. Province
NOTE: If you answered “Yes” to Item Number 2., attach
evidence of your legal name change with this application.

3.h. Postal Code
3.i.

Country

4.

Is your current mailing address the same as your U.S.
physical address?
Yes
No
If you answered “No” to Item Number 4., provide your
U.S. physical address in Item Numbers 5.a. - 5.e.

Form I-131A 02/13/19

Page 1 of 6

Part 1. Information About You (continued)

1.h.

My existing Form I-766, Employment Authorization
Document (with travel endorsement), has been damaged.

U.S. Physical Address

1.i.

Other (explain below).

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

Apt.

Ste.

Flr.

5.c. City or Town
5.d. State

Part 3. Processing Information
1.

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04/06/2020
5.e. ZIP Code

2.

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

3.

Date of Expiration of Existing Permanent
Resident Card (mm/dd/yyyy)

4.

Date of Expiration of Existing Reentry Permit
(if applicable) (mm/dd/yyyy)

5.

Date of Expiration of Existing Form I-512, I-512L, or
Form I-766 (if applicable) (mm/dd/yyyy)

6.

Receipt Number of Form I-131, Application for Travel
Document, Associated With the Lost, Stolen, or Damaged
Form I-512, I-512L, or I-766 (if applicable)

7.

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

Other Information
6.

Alien Registration Number (A-Number) (if any)
► A-

7.

USCIS Online Account Number (if any)
►

8.

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

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

9.

Date of Birth (mm/dd/yyyy)

10.

Gender

11.

Country of Birth

12.

Country of Citizenship or Nationality

Male

Female

1.a.

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

1.b.

My previous Permanent Resident Card was issued but
never received.

1.c.

My existing Permanent Resident Card has been
damaged.

1.d.

My existing Permanent Resident Card has already
expired.

1.e.

My existing Form I-512/Form I-512L, Advance
Parole Document, has been lost, stolen, or destroyed.

1.f.

My existing Form I-512/Form I-512L, Advance
Parole Document, has been damaged.

1.g.

My existing Form I-766, Employment Authorization
Document (with travel endorsement), has been lost,
stolen, or destroyed.

Form I-131A 02/13/19

No

If you answered “Yes” to Item Number 7., provide
details in the space provided in Part 7. Additional
Information.

Part 2. Reason for Application
Select only one box.

Yes

8.

If you are a lawful permanent resident, have you EVER
filed Form I-407, Record of Abandonment of Lawful
Permanent Resident Status, or otherwise been judged to
have abandoned your status?
Yes
No
If you answered “Yes” to Item Number 8., provide details
in the space provided in Part 7. Additional Information.

9.a. If you are a lawful permanent resident, have you EVER
been issued a Carrier Document?
Yes
No
If you answered “Yes” to Item Number 9.a., answer
Item Numbers 9.b. and 9.c. for the last document issued
to you and provide additional details in the space
provided in Part 7. Additional Information.
9.b. Date Issued (mm/dd/yyyy)
9.c. Disposition (attached, lost, etc.):

Page 2 of 6

Part 3. Processing Information (continued)

Applicant's Certification

10.a. If you received a Form I-512/I-512L, Advanced Parole
Document, or Form I-766, Employment Authorization
Document (with travel endorsement), was it ever
revoked?
Yes
No

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 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.

If you answered “Yes” to Item Number 10.a., answer
Item Numbers 10.b., and 10.c., for the last document
issued to you and provide additional details in the space
provided in Part 7. Additional Information.

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.

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04/06/2020

10.b. Date of Revocation (mm/dd/yyyy)
10.c. Reason for Revocation

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 1-131A
Instructions before completing this section.

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

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

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

Provide the following information about the interpreter.

,

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

NOTE TO ALL APPLICANTS: If you do not properly
complete this application or fail to submit required documents
listed in the Instructions, we may deny your application.

Interpreter's Full Name

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

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

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

prepared this application for me based only upon
information I 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-131A 02/13/19

Page 3 of 6

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

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

Provide the following information about the preparer.

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

Apt.

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

Province

3.g. Postal Code
3.h. Country

Preparer's Full Name

Ste.

Flr.

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

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04/06/2020

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

3.e. ZIP Code

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number
and Name

Interpreter's Contact Information
4.

3.b.

Interpreter's Daytime Telephone Number

Apt.

Ste.

Flr.

3.c. City or Town

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.d. State
3.f.

3.e. ZIP Code

Province

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-131A 02/13/19

Page 4 of 6

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
extends
does not extend beyond the
preparation of this application.

DRAFT
Not for
Production
04/06/2020

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.

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-131A 02/13/19

Page 5 of 6

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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

A-Number

3.a. Page Number

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

5.d.

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04/06/2020
► A-

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 02/13/19

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