I-102 Form - Table of Changes

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0079

02/24/2023

Reason for Revision: Limited REV

Project Phase: 30Day

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 12/31/2023

Edition Date 12/02/2021

Current Page Number and Section	Current Text	Proposed Text
Page 3, Part 4. Applicant’s Statement, Contact Information, Certification, and Signature	[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) 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 4. Applicant’s Contact Information, Certification, and Signature [deleted] Applicant’s Contact Information 1. Applicant’s Daytime Telephone Number 2. Applicant’s Mobile Telephone Number (if any) 3. Applicant’s Email Address (if any) 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. [deleted] 4. Applicant’s Signature Date of Signature (mm/dd/yyyy) [deleted]
Page 3-4, Part 5. Interpreter’s Contact Information, Certification, and Signature	[Page 3] 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) [Page 4] 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 3] Part 5. Interpreter’s Contact Information, Certification, and Signature [deleted] Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name [Page 4] [deleted] Interpreter’s Contact Information 3. Interpreter’s Daytime Telephone Number 4. Interpreter’s Mobile Telephone Number (if any) 5. Interpreter’s Email Address (if any) Interpreter’s Certification and Signature I certify, under penalty of perjury, that I am fluent in English and [Fillable language field], 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. [deleted] 6. Interpreter’s Signature Date of Signature (mm/dd/yyyy)
Page 4-5, Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant	[Page 4] 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) [Page 5] 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)	[Page 4] Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant [deleted] Preparer’s Full Name 1. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name [deleted] 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) [Page 5] [deleted] 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. [deleted] 6. Preparer’s Signature Date of Signature (mm/dd/yyyy)

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