Research Corporation of the University of Hawaiʻi

Human Resources Department
RCUH Form I-102
Created 10/05 (Revised 11/10, 11/13, 05/15, 04/16, 11/16, 02/20)
Research Corporation
of the University of Hawai‘i
DEPENDENT INFORMATION FORM
Complete this form when:
1.Your dependent will not initially accompany you to the U.S. but intend to join you at a later date, or
2.Your dependent is already in the U.S. and request for a change of status or extend their nonimmigrant status.
IMPORTANT NOTE: Your spouse and unmarried children under 21 years of age are eligible for H-4, TD or E-3D.
Part I: Biographical & Immigration Information
Dependent 1
1.Name on Passport:
Last Name (surname): _______________________________
First Name (given): _________________________________
Middle (if any): _____________________________________
2.Gender: Male Female
3.Date of Birth (mm/dd/yyyy):
4.Social Security Number (if any):
5.Nationality:
City of Birth: ____________________________________ Country of Citizenship: ______________________________________
Country of Birth: _________________________________ Country of Legal Permanent Residence: ________________________
6.Relationship to Beneficiary/Applicant:
Dependent 2
1.Name on Passport:
Last Name (surname): _______________________________
First Name (given): _________________________________
Middle (if any): _____________________________________
2.Gender: Male Female
3.Date of Birth (mm/dd/yyyy):
4.Social Security Number (if any):
5.Nationality:
City of Birth: ____________________________________ Country of Citizenship: ______________________________________
Country of Birth: _________________________________ Country of Legal Permanent Residence: ________________________
6.Relationship to Beneficiary/Applicant:
Dependent 3
1.Name on Passport:
Last Name (surname): _______________________________
First Name (given): _________________________________
Middle (if any): _____________________________________
2.Gender: Male Female
3.Date of Birth (mm/dd/yyyy):
4.Social Security Number (if any):
5.Nationality:
City of Birth: ____________________________________ Country of Citizenship: ______________________________________
Country of Birth: _________________________________ Country of Legal Permanent Residence: ________________________
6.Relationship to Beneficiary/Applicant:
*Please complete a second Dependent Information Form for any additional dependents.
Dependent Information Form
Page 2 of 2
RCUH Form I-102
Created 10/05 (Revised 11/10, 11/13, 05/15, 04/16, 11/16, 02/20)
Part II: Additional Information (Only applicable if Dependents are already in the U.S.)
Please submit the following:
1. Form I-539 and Form 1-539A: If your dependent(s) are now in the U.S., and request to change of status or to extend their nonimmigrant status, they must complete Form I-539 and Form I-539A (for additional dependents).
2. Proof of Relationship document
3. Copy of Passport and Form I-94: Include most recent Form I-94 arrival/departure record in passport if already in the U.S. If international travel and return is scheduled prior to submission of this petition, a copy of the I-94 record must be submitted to RCUH immediately upon return.
4. Form I-539 Filing Fee and additional biometrics service Fee: Filing fees are subject to change. Check the USCIS website at http://www.uscis.gov/forms for current rates. All checks must be made payable to the “Department of Homeland Security” or “U.S. Department of Homeland Security”. Forward the check(s) to RCUH Human Resources.
Part III: CERTIFICATION
Beneficiary/Applicant’s Certification:
I certify that the information provided on this form is accurate.
________________________________________ _______________________
Beneficiary/Applicant (Signature) Date
________________________________________
Beneficiary/Applicant (Print Name)
Dependent’s Certification:
I certify that the information provided on this form is accurate.
________________________________________ _______________________
Dependent (Signature) Date
________________________________________
Dependent (Print Name)