EFTA00173136 # Application for Replacement/Initial Nonimmigrant Arrival-Departure Document Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-102 OMB No. 1615-0079 Expires 10/31/2019
For USCIS Use OnlyReceiptAction BlockTo Be Completed by an Attorney or Accredited Representative, if any. ☐ Select this box if Form G-28 is attached to represent the applicant.
New I-94 NumberAn License
Remarks
▶ START HERE. Type or print in black ink ## Part 1. Information About You 1. Alien Registration Number (A-Number) 2. USCIS Online Account Number (if any) ## Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3. c. Middle Name ## U.S. Mailing Address ## 4.a. In Care Of Name 4. b. Street Number and Name 4. c. Apt. $ \surd $ Ste. $ \Box $ Flr. $ \Box $ NEW YORK 4. e. State [NY] 4.f. ZIP Code [10065] 5. 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. ## U.S. Physical Address 6. a. In Care Of Name 6. b. Street Number and Name 6. c. Apt. $ \Box $ Ste. 6. d. City or Town 6. e. State 6. f. ZIP Code ## Other Information (mm/dd/yyyy) ▶ 7. Date of Birth 8. Country of Birth 9. Country of Citizenship SLOVAKIA 10. U.S. Social Security Number (if any) Entry Information 11. Date of Last Entry into the United States (mm/dd/yyyy) ▶ 01/28/2020 12. Place of Last Entry into the United States (City and State) LOS ANGELES, CA Form I-102 10/19/17 N Page 1 of 4 EFTA00173137 ## Part 1. Information About You (continued) 13. Current Nonimmigrant Status E 2 VISA 14. Date Status Expires (mm/dd/yyyy) ▶ 03/25/2021 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 SLOVAKIA 15.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) ▶ 08/04/2020 ## 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.** $ \Box $ I am applying to replace my lost or stolen Form I-94 or I-94W. 1. b. $ \Box $ I am applying to replace my lost or stolen Form I-95. 1. c. $ \Box $ 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. 1. d. $ \Box $ I am applying to replace my Form I-95 because it was mutilated. I have attached my original Form I-95. 1. e. 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). 1. f. □ 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. 1. g. $ \Box $ 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. NEW PASSPORT 1.a. Are you filing this application with any other petition or application? $ \Box $ Yes $ \times $ No If "Yes" provide the USCIS Form Number and name of the application or petition you are filing in Item Number 1.b. EXPIRATION: 1. b. USCIS Form Number and Name ## Part 3. Processing Information 2. a. Are you now in removal proceedings? $ \Box $ Yes No If "Yes" complete Item Number 2.b. 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. 3.a. Family Name (Last Name) **NOTE:** Provide your name exactly as it appears on Form I-94, I-94W, or I-95. 3.b. Given Name (First Name) If you are unable to provide the original of your Form I-94, I-94W, or I-95, provide the following information: 3. c. Middle Name 4. Class of Admission at Last Entry into the United States E 2 5. Place of Last Entry into the United States (City and State) LOS ANGELES, CA Form I-102 10/19/17 N Page 2 of 4 EFTA00173138 ## 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. 1. b. □ The interpreter named below has read to me every question and instruction on this form, as well as my answer to every question, in 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. $ \Box $ I have requested the services of and consented to who is $ \Box $ is not $ \Box $ an attorney or accredited representative, preparing this form for me. ## 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. b. Date of Signature (mm/dd/yyyy) ▶ 7/14/2020 ## Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address 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. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) ## Interpreter's Mailing Address 3. a. Street Number and Name 3. b. Apt. $ \Box $ Ste. $ \Box $ Flr. $ \Box $ 3. c. City or Town 3. d. State $ \Box $ 3.e. ZIP Code $ \Box $ 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 Page 3 of 4 Form I-102 10/19/17 N EFTA00173139 ## Part 5. Contact Information, Certification, and Signature of the Interpreter (continued) ## Interpreter Certification I certify that: I am fluent in English and ___, which is the same language provided in Part 4., Item Number 1.b.; I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number 1.b.; and The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question. 6. a. Interpreter's Signature 6. b. Date of Signature (mm/dd/yyyy) ▶ Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1. a. Preparer's Family Name (Last Name) 1. b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name FBI ## Preparer's Mailing Address 3. a. Street Number and Name 26 FEDERAL PLAZA 3. b. Apt. $ \Box $ Ste. $ \Box $ Flr. $ \Box $ 3. c. City or Town NEW YORK 3. d. State 3. e. ZIP Code 3. f. Province 3. g. Postal Code 3. h. Country UNITED STATES ## Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number ## 6. Preparer's E-mail Address 7. a. I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant's consent. 7. b. $ \Box $ I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends $ \Box $ does not extend $ \Box $ beyond the preparation of this form. ## Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when required, supplied additional information to respond to a question on the form. NOTE: If you need extra space to provide any additional information, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. Page 4 of 4 Form I-102 10/19/17 N