DS-1884 PETITION TO CLASSIFY SPECIAL IMMIGRANT UNDER INA 203(b)

OMB APPROVED NO. 1405-0082
EXPIRATION DATE: XX/XX/20XX
ESTIMATED BURDEN: 10 minutes*

U.S. Department of State

PETITION TO CLASSIFY SPECIAL IMMIGRANT UNDER INA 203(b) (4) AS AN EMPLOYEE
OR FORMER EMPLOYEE OF THE U.S. GOVERNMENT ABROAD , OR THE SURVIVING
SPOUSE OR CHILD OF AN EMPLOYEE OF THE U.S. GOVERNMENT ABROAD
TYPE OF PRINT YOUR ANSWERS IN THE SPACE PROVIDE BELOW.
ONLY PROVIDE INFORMATION FOR THE DECEASED PRINCIPAL APPLICANT WHEN SPECIFICALLY INSTRUCTED.
DO NOT WRITE IN THIS BLOCK - FOR OFFICIAL USE ONLY
Date Petition Filed (mm-dd-yyyy) Fee collected

Approved for the Secretary of State: INA 204(a)(1)(G)(ii)

(Signature and Title)
Date (mm-dd-yyyy)

At

Recommendation of Principal Officer

ATTACHMENTS

Approval by the Secretary of State

SECTION 1: Personal Information
1a. Last Name(s) (List all spellings)
1b. First Name(s) (List all spellings)
1c. Middle Name(s) (List all spellings)
2. Date of Birth (mm-dd-yyyy)

3. Place of Birth

4. Are you applying as the surviving spouse or child of a deceased employee?
Yes

No

If yes, provide the following information for the deceased employee (4a-e).

4a. Full Name (Last Name(s), First Name(s)) (List all spellings)
4b. Date of Birth (mm-dd-yyyy)

4c. Place of Birth (City, State/Province, Country)

5. Employment History of Deceased Employee
5a. Total Number of Years of Employment by United States Government Abroad
5b. Location(s) of Employment

5c. Employment Status
Currently Employed
Honorably Retired
Deceased

5d. Employing U.S. Government Agency Name(s)

6. Provide information for Current and Former Spouse(s), if any
Name of Spouse
(Last Name(s), First Name(s), Middle Name(s)

Date of Birth
(mm-dd-yyyy)

Birth Place

a.
b.
c.
d.
DS-1884
03-2022

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6. Provide information for Child(ren), if any
Name of Child
(Last Name(s), First Name(s), Middle Name(s)

Date of Birth
(mm-dd-yyyy)

Birth Place

a.
b.
c.
d.
e.
f.
g.
SECTION 2: Acknowledgement
I understand that the Secretary of State has approved special immigrant status for me under the provisions of INA 101(a)(27)(D) and that such
approval remains valid for one year. In accordance with INA 204(a)(1)(G)(ii), I hereby petition for status under 203(b)(4) of the Immigration and
Nationality Act. I understand that the petition, if approved, remains valid for six months. If granted such status, I will pursue my application for an
immigrant visa immediately upon being notified that my petition has been approved. Also, upon approval of my petition, if I am then employed by the
United States Government, I certify that I intend permanent separation from such employment no later than the date of my departure for the United
States following issuance of an immigrant visa. I swear or affirm that all statements which appear in this petition are true and complete to the best of
my knowledge and belief. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may
subject me to permanent exclusion from the United States.

Signature of Applicant
Subscribed and sworn to before me this

day of

at
Consular Officer
Paperwork Reduction Act Statement - Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents
required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
[email protected].
Confidentiality Statement - INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only
for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of
visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the
court.
DS-1884

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