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Ype or Print (Use black ink) For USCIS Use Only Part 1. Information About You Family Name (Last Name) Receipt Returned Given Name (First Name) Middle Name Address - Street Number and Name Apt. No. Resubmitted C/O (in care of) City State Date of Birth (mm/dd/yyyy) ZIP Code Reloc Sent Country of Birth Country of Citizenship/Nationality U.S. Social Security No. (if any) A-Number (if any) Date of Last Arrival (mm/dd/yyyy) I-94 Number Current USCIS Status Expires on (mm/dd/yyyy) R.

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