Form DS-1884 Petition to Classify Special Immigrant Under INA 203(b)

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

OMB APPROVED NO.: 1405-0082
EXPIRATION DATE: 10/31/2006
ESTIMATED BURDEN: 10 minutes

DO NOT WRITE IN THIS BLOCK - FOR OFFICIAL USE ONLY
Date Petition Filed (mm-dd-yyyy) Fee collected:

Approved for the Secretary of State: INA 204(a)(1)(E)

(Signature and Title)
Date (mm-dd-yyyy)

At:

ATTACHMENTS
RECOMMENDATION OF PRINCIPAL OFFICER

APPROVAL BY THE SECRETARY OF STATE

1. NAME (Last, First, Middle)

2. DATE OF BIRTH (mm-dd-yyyy)

3. PLACE OF BIRTH

4. TOTAL NUMBER OF YEARS OF EMPLOYMENT BY UNITED STATES GOVERNMENT ABROAD
5. LOCATION(S) OF EMPLOYMENT
CURRENTLY EMPLOYED
HONORABLY RETIRED
7. EMPLOYING U.S. GOVERNMENT AGENCY NAMES(S)

8. NAME OF SPOUSE

DATE OF BIRTH (mm-dd-yyyy)

PLACE OF BIRTH

9. NAME(S) OF CHILD(REN)

DATE(S) OF BIRTH (mm-dd-yyyy) PLACE(S) OF BIRTH

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)(E), I hereby petition for status under 209(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. 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 swear or affirm that all statements which appear in this petition are true and complete to the best of my knowledge and
belief. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to
permanent exclusion from the United States.
Signature of Applicant
Subscribed and sworn to before me this

day of

at

Consular Officer
DS-1884
10-2003

*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 data, providing the information required, and reviewing the final collection. Send comments on the accuracy of this
estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, D.C. 20520, and to the Office of
Information and Regulatory Affairs, Office of Management and Budget.