Bureau of Population, Refugees and Migration ESTIMATED ...

1 5. Sex1. Case Size (Yourself plus family members traveling with you)2. Name as it Appears on your Passport (Last, First, Middle)3. Passport Ethnicity11. ReligionB. PRINCIPAL APPLICANTA. CASE INFORMATION (To be completed by NVC)NVC Case NumberAssigned PostPost POC Information13. E-mail12. Phone Number(s)DS-234 12-2020 Page 1 of 44. Sex2. Passport Ethnicity10. Religion12. E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13.

2 Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. ESTIMATED Delivery Date(mm-dd-yyyy)20. Health Issues (If yes, please explain ) Department of StateSPECIAL IMMIGRANT VISA BIODATA FORMB ureau of Population, Refugees and MigrationSpecial 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 CONTROL NO. 1405-0203 Expires: 05-31-2022 ESTIMATED BURDEN: 20 MIN.

3 To be completed by ApplicantMaleFemale4. IV Case Marital Status7. Date of Birth(mm-dd-yyyy)8. Place of Birth(City, Country)9. Nationality16. Native Language(Good, Some, None)17. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking14. Occupation/Skill15. Education Level/Field of Study18. English speaking Ability(Good, Some, None)19. PregnantYesNo20. ESTIMATED Delivery Date(mm-dd-yyyy)21. Health Issues (If yes, please explain )1. Name as it Appears on Passport (Last, First, Middle)C. SPOUSE4. Sex2. Passport Ethnicity10. Religion12. E-mail11. Phone Number(s)MaleFemale3.

4 IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. 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.)

5 Child 14. Sex2. Passport Ethnicity10. Religion12. E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. ESTIMATED Delivery Date(mm-dd-yyyy)20. Health Issues (If yes, please explain )1. Name as it Appears on Passport (Last, First, Middle)Child 24. Sex2. Passport Ethnicity10.

6 Religion12. E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. ESTIMATED Delivery Date(mm-dd-yyyy)20. Health Issues (If yes, please explain )1. Name as it Appears on Passport (Last, First, Middle)Child 3DS-234 Page 2 of 44. Sex2. Passport Ethnicity10. Religion12.

7 E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. 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.)

8 Child 44. Sex2. Passport Ethnicity10. Religion12. E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. ESTIMATED Delivery Date(mm-dd-yyyy)20. Health Issues (If yes, please explain )1. Name as it Appears on Passport (Last, First, Middle)Child 54. Sex2. Passport Ethnicity10.

9 Religion12. E-mail11. Phone Number(s)MaleFemale3. IV Case Marital Status6. Date of Birth(mm-dd-yyyy)7. Place of Birth(City, Country)8. Nationality15. Native Language(Good, Some, None)16. Other Language(s)(Good, Some, None)LanguageReadingLanguage 2 Language 1 Language 4 Language 3 WritingSpeaking13. Occupation/Skill14. Education Level/Field of Study17. English speaking Ability(Good, Some, None)18. PregnantYesNo19. ESTIMATED Delivery Date(mm-dd-yyyy)20. Health Issues (If yes, please explain )1. Name as it Appears on Passport (Last, First, Middle)Child 6DS-234 Page 3 of 4G. COMMENTS23. Do you have family members or friends already residing in the United States?

10 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. YesNoF. TIESLastFirstMiddleRelationship to youDate of Birth(dd mmm yyyy)If unknown,check boxSpecial Immigrant Visa Case Number1 234567 Family Member NameLastFirstMiddleRelationship to youGender4 32 Address1 NamePhone NumberE-mail AddressThe 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.