Form I-102 Form I-102 Application for Replacement/Initial Nonimmigrant Arrival

OMB No. 1615-0079; Expires 08/31/09

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

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

START HERE - Please type or print in black ink.
Part 1.

For USCIS Use Only

Family Name

Receipt

Returned

Information About You
Given Name

Middle Name

Date
Date
Resubmitted

Address - In care of Street Number and Name
In care of -

Apt./Suite #

City

Date
Date
Reloc Sent

State

Date
Zip/Postal Code

Date of Birth (mm/dd/yyyy)

Country

Country of Birth

Country of Citizenship/Nationality

A # (If any)

U.S. Social Security # (If any)

Date (mm/dd/yyyy) and Place of Last Admission

Current Nonimmigrant Status

Date
Reloc Rec'd
Date
Date
Applicant
Interviewed
on
New I-94 #

Status Expires on (mm/dd/yyyy)

Part 2.

I-94, I-94W, or I-95 Arrival/Departure Document #

Remarks

Reason for Application

Check the box that best describes your reason for requesting a replacement document
(Check one box).
a.

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

b.

I am applying to replace my lost or stolen Form I-95.

c.

I am applying to replace Form I-94 (or I-94W) because it is mutilated. I have
attached my original I-94 (or I-94W).

d.

I am applying to replace Form I-95 because it is mutilated. I have attached my
original Form I-95.

e.

I was not issued Form I-94 when I entered as a nonimmigrant, and I am filing
this application together with an application for an extension of stay/change of
status.

f.

I was issued Form I-94, I-94W, or I-95 with incorrect information, and I am
requesting USCIS to correct the document. I have attached my original Form
I-94, I-94W, or I-95.

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.

Action Block

To Be Completed by
Attorney or Representative, if any.
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #

Form I-102 Form (Rev. 08/21/08)Y

Part 3.

Processing Information

1. Are you filing this application with any other petition or application?
No

Yes - Form #

2. Are you now in removal proceedings?
No
Yes (Give detailed information regarding the proceedings. If you need more space to complete the answer, use a
separate sheet(s) of paper. Write your name and A #, if any, and "Part 3, Number 2" at the top of each sheet.)

3. If you are unable to provide the original of your Form I-94, I-94W, or I-95, give the following information:
Your name exactly as it appears on Form I-94, I-94W, or I-95, if known (Print clearly)

Class of Admission

Place of Admission

Part 4. Signature (Read the information on penalties in the instructions before completing this section. You must file this
application while in the United States.)

I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit I am seeking.
Signature

Daytime Telephone Number (With area code)
(

Date (mm/dd/yyyy)

)

Part 5. Signature of Person Preparing Form, if Other Than Above

(Sign below)

I declare that I prepared this application at the request of the above person, and it is based on all information of which I have
knowledge.
Signature

Print or Type Your Name

Firm Name

Firm Address (Street Number and Name or P.O. Box, City, State, Zip Code)

Daytime Telephone Number (With area code)

E-Mail Address (If any)

(

Date (mm/dd/yyyy)

)
Form I-102 Form (Rev. 08/21/08)Y Page 2