Form DS-0234 Special Immigrant Visa Biodata Form

U.S. Department of State

OMB APPROVAL NO. 1405--0203
EXPIRES: 01 -31 -xxxx
ESTIMATED BURDEN: 20 MIN.

Bureau of Population, Refugees and Migration

SPECIAL IMMIGRANT VISA BIODATA FORM
Special immigrant visa applicants who qualify for and request resettlement assistance from the Department of State must complete this form for each
family member and submit it via email as a scanned attachment to the National Visa Center at NVCSIV@state.gov .
A. CASE INFORMATION (To be completed by NVC)
NVC Case Number

Assigned Post

Post POC Information

2. Are you the principal applicant (PA)?

3. If not, what is your relationship to the PA?

B. CASE MEMBER

1. Case Size (Yourself plus family members
traveling with you)

(Husband, wife, son, daughter)
0

Yes

0

No

4. Name as it Appears on your Passport (Last, First, Middle)

5. Sex

D Male
6. Marital Status

7. Date of Birth (mm-dd-yyw)

8. Place of Birth (City, Country)

9. Nationality

10. Ethnicity

11 . Religion

D Female

12. Physical Address

..

13. Phone Number(s)

14. E-mail

15. Occupation/Skill

16. Education Level/Field of Study

17. Native Language

18. Other Language(s)

19. English Speaking Ability (Good, Some, None)

20. Pregnant

Estimated Delivery Date (EDD) (mm/ddlyyw)

{Select}
20. Health Issues (If yes, please explain)

C. CROSS REFERENCE

21. Do you have other immediate family members being processed on their own special immigrant visas? If yes, please provide your family member's
name, relationship to you, and special immigrant visa case number.

DS-234
xx-2015

D

Yes

Submit one copy of the Special Immigrant Visa Biodata form for each family member.
Send completed form(s) to the National Visa Center as an email attachment at NVCSIV@state.gov.

0

No

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FamHy Member Name
First

Last

!

Relationshlo to _,

Middle

Date of Bir1h
{dd mmm yyyy)
If unknown,
check box

Spec:ial lmmigrslt Visa

Case Number

D
D
D
D
D
D
D

1

2
3

4
5
8
7
D. U.S. TIES
22. Do you have family members or friends already residing in the United States? If yes, please provide family/friend information
below. It may be possible to be resettled near them . If the number exceeds 7, please include them in the comments section.

Relationship to you

Name
Last

First

Middle

Date of Birth
(dd mmm yyyy)
If unknown,
check box

1

D

2
3

D
D

4

D

5
8

D
D

7

D

Address

D

Yes

Phone Number

D

No

E-mail Address

t.

E. COMMENTS

CONFIDENTIALITY STATEMENT AND PAPERWORK REDUCTION ACT STATEMENT
The information asked for on this form is requested in accordance with Section 222(f) of the Immigration and Nationality Act, and is considered
confidential. The information provided herein shall only be shared with State Department personnel , officers of other federal agencies including the
Department of Health and Human Services and the Department of Homeland Security, and resettlement agency employees on a need to know basis.
The U.S. Department of State uses the facts you provide on this form to facilitate the provision of Resettlement and Placement benefits and to assist
in determining the location in the United States in which you will be resettled .
Public reporting burden for this collection of information is estimated to average 20 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 currf;)ntly 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: DOS/PRM, Office of Admissions, 2025 E Street. NW
Washington, DC 20522-0908.
DS-234

Submit one copy of the Special Immigrant Visa Biodata form for each family member.
Send completed form(s) to the National Visa Center as an email attachment at NVCSIV@state.gov.

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