DS-234 Form PDF >> DS-234 application form pdf Special Immigrant Visa Biodata Form

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 1. Case Size (Yourself plus family members traveling with you) 2. Name as it Appears on your Passport ( Last, First, Middle ) 3. Passport No. 10. Ethnicity 11. Religion B. PRINCIPAL APPLICANT A. CASE INFORMATION (To be completed by NVC) NVC Case Number Assigned Post Post POC Information 13. E-mail 12. Phone Number(s) DS-234 12-2020 Page 1 of 4 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues ( I f yes, please explain) 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 all family members and submit it via email as a scanned attachment to the Resettlement Support Center for the Middle East and North Africa (RSC MENA) at [email protected]. OMB CONTROL NO. 1405-0203 Expires: 08-31-2023 ESTIMATED BURDEN: 20 MIN. To be completed by Applicant Male Female 4. IV Case No. 6. Marital Status 7. Date of Birth ( mm-dd-yyy y) 8. Place of Birth (City, Country) 9. Nationality 16. Native Language (Good, Some, None) 17. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 14. Occupation/Skill 15. Education Level/Field of Study 18. English Speaking Ability (Good, Some, None) 19. Pregnant Yes No 20. Estimated Delivery Date ( mm-dd-yyyy ) 21. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) C. SPOUSE 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) D. Children (List children from eldest to youngest, if you have more than six children, please use the addendum sheet at the end of the form.) Child 1 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child 2 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child 3 DS-234 Page 2 of 4 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) D. Children - Continued (List children from eldest to youngest, if you have more than six children, please use the addendum sheet at the end of the form.) Child 4 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child 5 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child 6 DS-234 Page 3 of 4 G. COMMENTS 23. 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 F. U.S. TIES 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 Gender 4 3 2 Address 1 Name Phone Number E-mail Address 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. 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 Page 4 of 4 DS-234 E. CROSS REFERENCE 22. 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 5 6 7 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) D. Children (Continued from page 3, if necessary) Child 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child 4. Sex 2. Passport No. 9. Ethnicity 10. Religion 12. E-mail 11. Phone Number(s) Male Female 3. IV Case No. 5. Marital Status 6. Date of Birth ( mm-dd-yyy y) 7. Place of Birth (City, Country) 8. Nationality 15. Native Language (Good, Some, None) 16. Other Language(s) (Good, Some, None) Language Reading Language 2 Language 1 Language 4 Language 3 Writing Speaking 13. Occupation/Skill 14. Education Level/Field of Study 17. English Speaking Ability (Good, Some, None) 18. Pregnant Yes No 19. Estimated Delivery Date ( mm-dd-yyyy ) 20. Health Issues (If yes, please explain) 1. Name as it Appears on Passport ( Last, First, Middle ) Child DS-234 Addendum page(s)