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 12/31/2023

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.

DRAFT
NOT FOR
PRODUCTION
02/24/2023
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.

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 Edition 12/02/21

Apt.

Ste.

Flr.

7.d. City or Town
7.f.

ZIP Code

Page 1 of 5

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.

Entry Information
12.

13.

14.

15.

I am applying to replace my lost or stolen Form I-94
or Form I-94W.

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NOT FOR
PRODUCTION
02/24/2023

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

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.

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 Edition 12/02/21

Page 2 of 5

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

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

Yes

No

If you answered "Yes" to Item Number 2.a., complete
Item Number 2.b.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

DRAFT
NOT FOR
PRODUCTION
02/24/2023

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.

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name

Interpreter's Contact Information

Part 4. Applicant's Contact Information,
Certification, and Signature
Applicant's Contact Information
1.

Applicant's Daytime Telephone Number

2.

Applicant's Mobile Telephone Number (if any)

3.

Interpreter's Daytime Telephone Number

4.

Interpreter's Mobile Telephone Number (if any)

5.

Interpreter's E-mail Address (if any)

Interpreter's Certification and Signature

I certify under penalty of perjury, that I am fluent in English and

3.

Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my application, I read and understand or, if interpreted to
me in a language in which I am fluent by the interpreter listed in
Part 5., understood, all of the responses and information
contained in, and submitted with, my application, and that all of
the responses and the information is complete, true, and correct.
Furthermore, I authorize the release of any information from
any and all of my records that USCIS may need to determine
my eligibility for an immigration request and to other entities
and persons where necessary for the administration and
enforcement of U.S. immigration law.
4.

,

Applicant's Email Address (if any)

and I have interpreted every question on the application and
Instructions and interpreted the applicant's answers to the
questions in that language, and the applicant informed me that
they understood every instruction, question, and answer on the
application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Applicant's Signature

Date of Signature (mm/dd/yyyy)

Form I-102 Edition 12/02/21

Page 3 of 5

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
Preparer's Full Name
1.

DRAFT
NOT FOR
PRODUCTION
02/24/2023

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

4.

Preparer's Mobile Telephone Number (if any)

5.

Preparer's Email Address (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this
application for the applicant at their request and with express
consent and that all of the responses and information contained
in and submitted with the application is complete, true, and
correct and reflects only information provided by the applicant.
The applicant reviewed the responses and information and
informed me that they understand the responses and information
in or submitted with the application.
6.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

Form I-102 Edition 12/02/21

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 (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.

DRAFT
NOT FOR
PRODUCTION
02/24/2023

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 Edition 12/02/21

4.c. Item Number

7.a. Page Number

7.d.

Page 5 of 5