Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services Receipt Action Block USCIS Form I-102 OMB No. 1615-0079 Expires 10/31/2017 For USCIS Use Only New I-94 Number To Be Completed by an Attorney or Accredited Representative, if any. Select this box if Form G-28 is attached to represent the applicant. Attorney State License Number Remarks START HERE. Type or print in black ink Part 1. Information About You 1. Alien Registration Number (A-Number) U.S. Physical Address 6.a. In Care Of Name A2. USCIS Online Account Number (if any) 6.b. Street Number and Name 6.c. Apt. Ste. Flr. Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 6.d. City or Town 6.e. State 6.f. ZIP Code Other Information 7. Date of Birth Country of Birth (mm/dd/yyyy) U.S. Mailing Address 4.a. In Care Of Name 8. 9. 4.b. Street Number and Name 10. 4.c. Apt. Ste. Flr. 4.d. City or Town Country of Citizenship U.S. Social Security Number (if any) Entry Information 4.e. State 5. 4.f. ZIP Code 11. Is your current U.S. mailing address the same as your U.S. physical address? Yes No If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.f. 12. Date of Last Entry into the United States (mm/dd/yyyy) Place of Last Entry into the United States (City and State) Form I-102 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 Part 1. Information About You (continued) 13. Current Nonimmigrant Status Part 3. Processing Information 1.a. Are you filing this application with any other petition or application? Yes No If "Yes" 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 14. Date Status Expires (mm/dd/yyyy) 15.a. Form I-94, I-94W, or I-95 Arrival-Departure Record Number 15.b. Passport Number 15.c. Travel Document Number 15.d. Country of Issuance for Passport or Travel Document 2.a. Are you now in removal proceedings? If "Yes" complete Item Number 2.b. Yes No 15.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 2.b. Provide detailed information regarding the proceedings. If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) 1.a. 1.b. 1.c. I am applying to replace my lost or stolen Form I-94 or I-94W. I am applying to replace my lost or stolen Form I-95. I am applying to replace my Form I-94 or I-94W because it was mutilated. I have attached my original Form I-94 or I-94W. I am applying to replace my Form I-95 because it was mutilated. I have attached my original Form I-95. 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). I was issued Form I-94, I-94W, or I-95 with incorrect information, and I am requesting that USCIS correct the document. I have attached my original Form I-94, I-94W, or I-95. 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. If you are unable to provide the original of your Form I-94, I-94W, or I-95, provide the following information: NOTE: Provide your name exactly as it appears on Form I-94, I-94W, or I-95. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Class of Admission at Last Entry into the United States 1.d. 1.e. 1.f. 1.g. 5. Place of Last Entry into the United States (City and State) Form I-102 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Part 4. Statement, Certification, Signature, and Contact Information of the Applicant 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 have read and understand every question and instruction on this form, as well as my answer to every question. The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in Part 5. Contact Information, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) 1.b. 1.b. Interpreter's Given Name (First Name) , a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above. 2. I have requested the services of and consented to 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name , who is is not an attorney or accredited representative, preparing this form for me. 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code Applicant Certification I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents, and I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigration laws. 3.a. Applicant's Signature 3.f. Province 3.g. Postal Code 3.h. Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address 3.b. Date of Signature (mm/dd/yyyy) Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Form I-102 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Part 5. Contact Information, Certification, and Signature of the Interpreter (continued) Interpreter Certification I certify that: Preparer's