U.S. Department of State Bureau of Population, Refugees and Migration OMB APPROVAL NO. 1405-0015 EXPIRES: 10/31/2012 ESTIMATED BURDEN: 20 MIN. 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 B. CASE MEMBER 1. Case Size (Yourself plus family members traveling with you) 2. Are you the principal applicant (PA)? 3. If not, what is your relationship to the PA? (Husband, wife, son, daughter) Yes No 4. Name as it Appears on your Passport (Last, First, Middle) 5. Sex Male Female 6. Marital Status 7. Date of Birth (mm-dd-yyyy) 8. Place of Birth (City, Country) 9. Nationality 10. Ethnicity 11. Religion 12. Physical Address 13. Phone Number(s) 14. Email 15. Last Occupation/Skill 16. Education Level/Field of Study 17. Native Language 18. Other Language(s) 19. English Speaking Ability (Good, Some, None) DS-0234 02-2009 20. Health Problems (Condition, Treatment, Urgency, Comments) 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 . Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com C. CROSS REFERENCE 21. Do you have other immediate family members being processed on their own special immigrant visas? Yes No 22. If yes, do you wish to be resettled in the same city in the United States? If yes, please provide family's name, relationship to you and their special immigrant visa case number. Yes No D. U.S. TIES 23. Do you have family members already residing in the United States? If yes, please provide family information below. It may be possible to be resettled near them. Yes No 25. Birth Date (mm-dd-yyyy) (If known) 24. U.S. Relative's Name (Last, First, Middle) 26. Address 27. Phone Number 28. Relationship to You 29. Email Address E. COMMENTS The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue you a Social Security Number and card. 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 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: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202 DS-0234 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 . Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com