Fillable Printable Form I-131A
Fillable Printable Form I-131A
Form I-131A
Form I-131A 12/23/16 N Page 1 of 5
Application for Travel Document (Carrier Documentation)
Department of Homeland Security
U.S. Citizenship and Immigration Services
To be completed by an
attorney or accredited
representative (if any).
Select this box if
Form G-28 or
Form G-28I is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
For
USCIS
Use
Only
Action Block
Receipt
Date:
(mm/dd/yyyy)
By:
Document Hand Delivered
Document Issued
Transportation Letter Boarding Foil
USCIS
Form I-131A
OMB No. 1615-0135
Expires 08/31/2018
Part 1. Information About You
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
START HERE - Type or print in black ink.►
Current Mailing Address
3.d. City or Town
3.e. State 3.f. ZIP Code
3.g.
Postal Code
Street Number
and Name
3.b.
3.c. Flr.Apt. Ste.
3.h.
3.i. Country
Province
3.a. In Care Of Name (if any)
Date of Birth (mm/dd/yyyy)9.
6.
7.
►
A-
Alien Registration Number (A-Number)
Other Information
5.c. City or Town
5.d. State 5.e. ZIP Code
5.a.
5.b. Ste. Flr.Apt.
U.S. Physical Address
Street Number
and Name
Has your name changed since the issuance of your last
Permanent Resident Card (Form I-551)?
NoYes
2.
NOTE: If you answered "Yes" to Item Number 2., attach
evidence of your legal name change with this application.
If you answered "No" to Item Number 4., provide your U.S.
physical address in Item Numbers 5.a. - 5.e.
►
USCIS Online Account Number (if any)
U.S. Social Security Number (if any)8.
►
FemaleMaleSex10.
Is your current mailing address the same as your U.S.
physical address?
NoYes
4.
Form I-131A 12/23/16 N Page 2 of 5
Since you were granted permanent residence, have you
EVER filed Form I-407, Abandonment of Lawful
Permanent Resident Status, or otherwise been judged to
have abandoned your status?
Have you EVER been issued a Travel Document? 5.a.
NoYes
Part 3. Processing Information
NoYes
4.
Are you NOW, or were you EVER, in exclusion,
deportation, removal, or rescission proceedings?
3.
NoYes
If you answered "Yes" to Item Number 3., provide
details in the space provided in Part 7. Additional
Information.
If you answered "Yes" to Item Number 4., provide
details in the space provided in Part 7. Additional
Information.
If you answered "Yes" to Item Number 5.a., answer Item
Numbers 5.b. and 5.c. for the last document issued to you
and provide additional details in the space provided in
Part 7. Additional Information.
Date Departed the United States (mm/dd/yyyy)1.
(mm/dd/yyyy)
Date of Intended Travel to the United States2.
2. At my request, the preparer named in Part 6.,
prepared this application for me based only upon
information I provided or authorized.
,
Part 2. Reason for Application
(Select only one box):
My previous Permanent Resident Card has been lost,
stolen, or destroyed
My previous Permanent Resident Card was issued but
never received
My existing Permanent Resident Card has been
mutilated
My existing Permanent Resident Card has already
expired
Other (explain below):
1.a.
1.b.
1.c.
1.d.
1.e.
a language in which I am fluent and I understood
everything.
The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in
1.b.
,
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.a.
Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
NOTE: Read the Penalties section of the Form 1-131A
Instructions before completing this part.
Applicant's Statement
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
Applicant's Contact Information
Part 1. Information About You (continued)
12. Country of Citizenship or Nationality
11. Country of Birth
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit I seek.
Applicant's Certification
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
Disposition (attached, lost, etc.):5.c.
Date Issued (mm/dd/yyyy)5.b.
Form I-131A 12/23/16 N Page 3 of 5
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any) 6.
Interpreter's Certification
I certify, under penalty of perjury, that:
which is the same language specified in Part 4., Item
Number 1.b., and I have read to this applicant in the identified
language every question and instruction on this application and
his or her answer to every question. The applicant informed me
that he or she understands every instruction, question, and
answer on the application, including the Applicant's
Certification, and has verified the accuracy of every answer.
I am fluent in English and ,
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature6.a.
I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
Applicant's Signature
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
Part 5. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Interpreter's Given Name (First Name)1.b.
Interpreter's Business or Organization Name (if any)2.
Provide the following information about the interpreter.
Interpreter's Signature7.a.
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Flr.
Apt. Ste.
3.g.
3.h. Country
Province
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
I reviewed and understood all of the information
contained in, and submitted with, my application; and
All of this information was complete, true, and correct
at the time of filing.
1)
2)
5. Interpreter's Mobile Telephone Number (if any)
Form I-131A 12/23/16 N Page 4 of 5
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Flr.Apt. Ste.
3.g.
3.h. Country
Province
Part 6. Contact Information and Signature of the
Person Preparing this Application, if Other Than
the Applicant
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
6. Preparer's Email Address (if any)
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
I am an attorney or accredited representative and my
representation of the applicant in this case
7.a.
7.b.
preparation of this application.
Preparer's Statement
does not extend beyond the extends
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the
Geographical Confines of the United States, with this
application.
Preparer's Business or Organization Name (if any)2.
Preparer's Given Name (First Name)1.b.
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
Form I-131A 12/23/16 N Page 5 of 5
Part 7. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.
A-Number ►
A-
3.a.
2.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
Page Number
Part Number Item Number
Page Number Part Number Item Number5.a.
Page Number
7.a. 7.b. 7.c.
Item NumberPart NumberPage Number
5.b.
Part Number
5.c.
Item Number
5.d.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
4.c.4.b.
4.d.
4.a.
6.d.
7.d.
6.c.6.b.6.a.
