Fillable Printable Form DS-234
Fillable Printable Form DS-234
Form DS-234
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 [email protected] .
DS-234
03-2016
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 [email protected] .
A. CASE INFORMATION (To be completed by NVC)
NVC Case Number Assigned Post Post POC Information
OMB APPROVAL NO. 1405-0203
EXPIRES: 03-31-2019
ESTIMATED BURDEN: 20 MIN.
Estimated Delivery Date (EDD) (mm/dd/yyyy)
(Select)
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 [email protected] .
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 2DS-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
(Select)
(Select)
(Select)
(Select)
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