4. Name as it Appears on your Passport (Last, First, Middle) 18. Other Language(s) 17. Native Language 16. Education Level/Field of Study 15. Occupation/Skill 14. E-mail 13. Phone Number(s) 19. English Speaking Ability (Good, Some, None) 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. Yes No 20. Pregnant 3. If not, what is your relationship to the PA? (Husband, wife, son, daughter) 1. Case Size (Yourself plus family members traveling with you) 2. Are you the principal applicant (PA)? Yes No 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 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 . DS-234 05-2017 Page 1 of 2 B. CASE MEMBER U.S. Department of State SPECIAL IMMIGRANT VISA BIODATA FORM Bureau of Population, Refugees and Migration 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 OMB APPROVAL NO. 1405-0203EXPIRES: 08-31-2019ESTIMATED BURDEN: 20 MIN. Estimated Delivery Date (EDD) (mm/dd/yyyy) E. COMMENTS 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. Yes No D. U.S. TIES 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 . 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. Page 2 of 2 DS-234 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: DOS/PRM, Office of Admissions, 2025 E Street, NW Washington, DC 20522-0908. CONFIDENTIALITY STATEMENT AND PAPERWORK REDUCTION ACT STATEMENT Last First Middle Relationship to you Date of Birth (dd mmm yyyy) If unknown, check box Special Immigrant Visa Case Number 1 2 3 4 5 6 7 Family Member Name Last First Middle Relationship to you Date of Birth (dd mmm yyyy) If unknown, check box 3 2 Address 1 Name Phone Number E-mail Address 6 5 4 7