DS-1884 Form pdf >> DS-1884 Application form Petition to Classify Special Immigrant Under INA 203(b)(4) as an Employee or Former Employee of the U.S. Government Abroad

DS-1884 Application form, Ds 1884 Form, DS-1884 Application form Download , Ds 1884 Form pdf, Petition to Classify Special Immigrant Under INA 203(b)(4) as an Employee or Former Employee of the U.S. Government Abroad,

Fee collected Date Petition Filed (mm-dd-yyyy) Approved for the Secretary of State: INA 204(a)(1)(G)(ii) (Signature and Title) Date (mm-dd-yyyy) At ATTACHMENTS Recommendation of Principal Officer Approval by the Secretary of State DO NOT WRITE IN THIS BLOCK - FOR OFFICIAL USE ONLY 3. Place of Birth (City, State/Province, Country) 2. Date of Birth (mm-dd-yyyy) 1a. Last Name(s) (List all spellings) SECTION 1: Principal Applicant Information 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, OR THE SURVIVING SPOUSE OR CHILD OF AN EMPLOYEE OF THE U.S. GOVERNMENT ABROAD DS-1884 06-2022 Page 1 of 2 5a. Total Number of Years of Employment by United States Government Abroad 5b. Employment Status Currently Employed Honorably Retired Deceased Other 5c. U.S. Government Employment History Position Title and Grade Dates of Service (mm-dd-yyyy) Start Date End Date Location of Employment Employing U.S. Government Agency's Name SECTION 2: Employment History of U.S. Government Employee OMB APPROVED NO. 1405-0082 EXPIRATION DATE: 07/31/2026 ESTIMATED BURDEN: 10 minutes* TYPE OR PRINT YOUR ANSWERS IN THE SPACE PROVIDED BELOW. ONLY PROVIDE INFORMATION FOR THE DECEASED EMPLOYEE WHEN SPECIFICALLY INSTRUCTED. 1b. First Name(s) (List all spellings) 1c. Middle Name(s) (List all spellings) 4a. Full Name (Last Name(s), First Name(s)) (List all spellings) 4c. Place of Birth ( City, State/Province, Country ) 4d. Date of Death (mm-dd-yyyy) 4b. Date of Birth (mm-dd-yyyy) 4. Are you applying as the surviving spouse or child of a deceased employee? Yes No If yes, provide the following information for the deceased employee (4a - 4d). If no, proceed to Section 2 below. 7. Provide information for Child(ren), if any Name of Child Last Name, First Name, Middle Name (list all spellings) Date of Birth (mm-dd-yyyy) Birth Place ( City, State/Province, Country ) a. b. c. d. e. f. g. SECTION 4: Acknowledgement 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 (or, if a visa number is not available at that time, as soon as it becomes available). 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 understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information for purposes including enforcement of the laws in the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of the United States of America that the foregoing is complete, true and correct. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may result in refusal of the visa or denial of the admission to the United States, and may subject me to criminal prosecution and/or removal from the United States. Signature of Applicant 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]. 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 Page 2 of 2 Date (mm-dd-yyyy) a. b. c. d. Name of Spouse Last Name, First Name, Middle Name (list all spellings) Date of Birth (mm-dd-yyyy) Birth Place ( City, State/Province, Country ) Dates of Marriage (mm-dd-yyyy) Start Date End Date 6. Provide information for Current and Former Spouse(s), if any. NOTE: "End Date" corresponds to the date of divorce or date of spouse's death. SECTION 3: Family Information