Application for Travel Document (Carrier Documentation) Department of Homeland Security U.S. Citizenship and Immigration Services Receipt USCIS Form I-131A OMB No. 1615-0135 Expires 08/31/2018 Action Block For USCIS Use Only Document Issued Transportation Letter Boarding Foil Document Hand Delivered By: Date: (mm/dd/yyyy) To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 or Form G-28I is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. Part 1. Information About You 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Has your name changed since the issuance of your last Permanent Resident Card (Form I-551)? Yes No 4. Is your current mailing address the same as your U.S. physical address? Yes No If you answered "No" to Item Number 4., provide your U.S. physical address in Item Numbers 5.a. - 5.e. U.S. Physical Address 5.a. Street Number and Name 5.b. Apt. Ste. Flr. NOTE: If you answered "Yes" to Item Number 2., attach evidence of your legal name change with this application. 5.c. City or Town 5.d. State 5.e. ZIP Code Current Mailing Address 3.a. In Care Of Name (if any) Other Information 3.b. Street Number and Name 3.c. Apt. Ste. Flr. 6. Alien Registration Number (A-Number) A7. USCIS Online Account Number (if any) 3.d. City or Town 8. 3.e. State 3.g. Province 3.h. Postal Code 3.i. Country 3.f. ZIP Code 9. 10. Date of Birth (mm/dd/yyyy) Sex Male Female U.S. Social Security Number (if any) Form I-131A 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 5 Part 1. Information About You (continued) 11. Country of Birth 5.b. Date Issued (mm/dd/yyyy) 5.c. Disposition (attached, lost, etc.): 12. Country of Citizenship or Nationality Part 4. Applicant's Statement, Contact Information, Certification, and Signature Part 2. Reason for Application (Select only one box): 1.a. 1.b. 1.c. 1.d. 1.e. My previous Permanent Resident Card has been lost, stolen, or destroyed My previous Permanent Resident Card was issued but never received My existing Permanent Resident Card has been mutilated My existing Permanent Resident Card has already expired Other (explain below): NOTE: Read the Penalties section of the Form 1-131A Instructions before completing this part. 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. The interpreter named in Part 5. read to me every question and instruction on this application and my answer to every question in , a language in which I am fluent and I understood everything. 2. At my request, the preparer named in Part 6., , prepared this application for me based only upon information I provided or authorized. 1.b. Part 3. Processing Information 1. Date Departed the United States (mm/dd/yyyy) 2. Date of Intended Travel to the United States (mm/dd/yyyy) Applicant's Contact Information 3. No 4. Applicant's Mobile Telephone Number (if any) Applicant's Daytime Telephone Number 3. Are you NOW, or were you EVER, in exclusion, deportation, removal, or rescission proceedings? Yes If you answered "Yes" to Item Number 3., provide details in the space provided in Part 7. Additional Information. 5. Applicant's Email Address (if any) 4. Since you were granted permanent residence, have you EVER filed Form I-407, Abandonment of Lawful Permanent Resident Status, or otherwise been judged to have abandoned your status? Yes No If you answered "Yes" to Item Number 4., provide details in the space provided in Part 7. Additional Information. 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 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 laws. American LegalNet, Inc. www.FormsWorkFlow.com 5.a. Have you EVER been issued a Travel Document? Yes No If you answered "Yes" to Item Number 5.a., answer Item Numbers 5.b. and 5.c. for the last document issued to you and provide additional details in the space provided in Part 7. Additional Information. Form I-131A 12/23/16 N Page 2 of 5 Part 4. Applicant's Statement, Contact Information, Certification, and Signature (continued) I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.f. Province 3.e. ZIP Code 3.g. Postal Code 3.h. Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number Applicant's Signature 6.a. Applicant's Signature 5. Interpreter's Mobile Telephone Number (if any) 6. 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. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and , Part 5. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1.a. Inter