Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0079; Expires 07/30/08
Part 1. Information about you.
Part 2. Reason for application.
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 Form I-94 (or I-94W) because it is mutilated. I have
attached my original I-94 (or I-94W).
I am applying to replace Form I-95 because it is mutilated. I have attached my
I was not issued a Form I-94 when I entered as a nonimmigrant, and I am filing
this application together with an application for an extension of stay/change of
START HERE - Please type or print in black ink.
I-102, Application for Replacement/Initial
Nonimmigrant Arrival - Departure Document
Form I-102 Form (Rev. 07/30/07)Y
Attorney or Representative, if any.
To Be Completed by
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #
For USCIS Use Only
New I-94 #
Street Number and Name
In care of -
Address - In care of -
Country of Birth
Country of Citizenship/Nationality
Date of Birth (mm/dd/yyyy)
A # (if any)
U.S. Social Security # (if any)
Date (mm/dd/yyyy) and Place of Last Admission
I-94, I-94W or I-95 Arrival/Departure Document #
Status Expires on (mm/dd/yyyy)
Current Nonimmigrant Status
Check the box that best describes your reason for requesting a replacement document.
(Check one box.)
I was not issued a 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.
I was issued a Form I-94, I-94W or Form I-95 with incorrect information, and I
am requesting USCIS to correct the document. I have attached my original
Form I-94, I-94W or