U.S. Department of State NONIMMIGRANT V VISA APPLICATION Approved OMB 1405-0128 Expires 11-30-2009 Estimated Burden 1 hour * Use with Form DS-156 The following questions must be answered by all applicants for a V visa. This form, together with Form DS-156, Nonimmigrant Visa Application, constitutes the application for a V visa. 1. Family Name First Name 2. Date of Birth (mm-dd-yyyy) Middle Name 3. Place of Birth (City, Province, Country) 4. Mailing Address 5. Telephone Number 6. Petition Information A. Who filed the petition? Check one box: Spouse Parent B. Name of Spouse or Parent C. Date and Place of Birth of Spouse or Parent D. Mailing Address and Telephone Number of Spouse or Parent E. When did your spouse or parent file the petition? F. Do you or your spouse or parent have a copy of the form 1-797, "Notice of Action", from the Bureau of Citizenship and Naturalization Services (BCIS)? If yes, send a copy of the receipt notice with this form. Do not send the original. You No Yes will need the original at the interview. G. If the petition was filed by your spouse, please write the date and place of the marriage. H. If the petition was filed by your parent, have you ever been married? I have never been married. I am married now. Date and place of marriage I was married, but am not married anymore. I am: Divorced 7. List name, date, and place of birth of all unmarried children under age 21. Name Birth Date (mm-dd-yyyy) Widowed Birth Place (City, Province, Country) 8. List all the places you have lived since the age of 16. Do not include places that you visited for six months or less. City Country Dates that you lived there (mm-dd-yyyy) to to Notice to unmarried children under age 21 filing this application: If you marry after receiving the V visa, but before you have adjusted status to lawful permanent resident, you will no longer be eligible to enter the United States or remain in the United States on a V nonimmigrant visa. I certify that I have read and understood all the questions in this application and that the answers I have provided on this form are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement may result in the permanent refusal of a visa or denial of entry into the United States. Date (mm-dd-yyyy) Signature of Applicant Signature of Person who Prepared Application if other than Applicant Date (mm-dd-yyyy) Privacy Act and Paperwork Reduction Act Statements INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the court. *Public reporting burden for this collection of information is estimated to average 1 hour per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. You do not have to provide the information unless this collection displays a currently valid OMB number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State, A/ISS/DIR, 1800 G Street, Washington, DC 20522. DS-3052 12-2006 American LegalNet, Inc. www.FormsWorkflow.com