Fillable Printable Form DS-1884

Form DS-1884

Fee collectedDate Petition Filed (mm-dd-yyyy) Approved for the Secretary of State: INA 204(a)(1)(G)(ii)

(Signature and Title)

Date (mm-dd-yyyy)

ATTACHMENTS

Recommendation of Principal Officer

Approval by the Secretary of State

3. Place of Birth

1. Name (Last, First, Middle)

5. Location(s) of Employment

2. Date of Birth (mm-dd-yyyy)

U.S. Department of State

PETITION TO CLASSIFY SPECIAL IMMIGRANT UNDER

INA 203(b) (4) AS AN EMPLOYEE OR FORMER EMPLOYEE

OF THE U.S. GOVERNMENT ABROAD

DO NOT WRITE IN THIS BLOCK - FOR OFFICIAL USE ONLY

4. Total Number of Years of Employment by United States Government Abroad

Currently Employed

Honorably Retired

7. Employing U.S. Government Agency Name(s)

8. Name of Spouse

Date of Birth (mm-dd-yyyy)

Place of Birth

9. Name(s) of Child(ren)

Date(s) of Birth (mm-dd-yyyy)

Place(s) of Birth

I understand that the Secretary of State has approved special immigrant status for me under the provisions of INA 101(a)(27)(D) and that

such approval remains valid for one year. In accordance with INA 204(a)(1)(G)(ii), I hereby petition for status under 203(b)(4) of the

Immigration and Nationality Act. I understand that the petition, if approved, remains valid for six months. If granted such status, I will pursue

my application for an immigrant visa immediately upon being notified that my petition has been approved. Also, upon approval of my

petition, if I am then employed by the United States Government, I certify that I intend permanent separation from such employment no later

than the date of my departure for the United States following issuance of an immigrant visa. I swear or affirm that all statements which

appear in this petition are true and complete to the best of my knowledge and belief. I understand that any willfully false or misleading

statement or willful concealment of a material fact made by me herein may subject me to permanent exclusion from the United States.

*Paperwork Reduction Act Statement - Public reporting burden for this collection of information is estimated to average 10 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: [email protected] .

Signature of Applicant

Subscribed and sworn to before me this day of

Consular Officer

Confidentiality Statement - 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.

DS-1884

12-2015

OMB APPROVED NO. 1405-0082

EXPIRATION DATE: 12/31/2018

ESTIMATED BURDEN: 10 minutes*

SECTION 1: Personal Information

SECTION 2: Acknowledgement