REFUGEE INFORMATION FORM

LOCAL AFFILIATE:

RA :

DATE:

CROSS REFERENCE (NAME, RELATION & DOB):

WRAPS AFFILIATE CODE:

DATE RECEIVED AT RSC/AUSTRIA
(FOR INTERNAL USE ONLY):

EXISTING CASE NUMBER:

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

Please be aware that this application constitutes a request to participate in the U.S. Refugee Admissions Program. It should be noted that completion and submission of this form does not
guarantee the issuance of a D Visa nor does it guarantee admission to the United States as a refugee. Processing times can vary widely and can range from months to years depending on timely
submission of documents/information, security clearances, and payments of Care & Maintenance funds. If the individuals on this application need to leave Iran urgently, please tick the expedite
box on the Application Checklist and submit an explanation. Cases can be expedited at any point in the process. Should the applicants situation change, please provide an explanation to your local
resettlement agency regarding why the case now needs to be expedited.
D .
. C&M . .
. .( expedite box)
.
INSTRUCTIONS: A Refugee Information Form (RIF) can be filed by anyone legally residing in the U.S. The person for whom the RIF is filed must be personally known by the U.S. tie. The principal
applicant (PA) must be a member of an eligible religious minority group in Iran (for this particular program) and reside in Iran at the time of this application.
All sections of the RIF must be filled out in English with the assistance of a local resettlement agency. All dates given should be as specific as possible in the format 05/JAN/1965 or, at a minimum,
month and year. All required documentation (as indicated on the Application Checklist) must be included in the application packet. Failure to submit a complete RIF and all required documentation
will result in serious delays or could result in the application not being accepted for further processing.
It is required that the applicant(s) have a current passport(s) at the time of submission of this application.
All application packets (RIF and all required documents) must be mailed to RSC/Austria by the local resettlement agency. Electronic submissions will not be accepted.
A case number will be issued and sent to the resettlement agency once RSC/Austria receives the application. All applicants must check HIAS RSC/Austrias website (www.hias-vienna.at) regularly for
updates regarding the case.
. U.S. tie .( RIF) :
(RIF) .
05/Jan/1965 .
) .
. RIF .(
. )(
. . RSC/Austria RIF
. RSC/Austria
. www.hias-vienna.at RSC/Austria

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 1: U.S. TIE INFORMATION

NAME: LAST, FIRST, MIDDLE

GENDER

DATE OF BIRTH

CITY/COUNTRY
OF BIRTH

LEGAL STATUS
IN USA

MARITAL
STATUS

ALIEN NUMBER

NUMBER OF
MARRIAGES

RELATION TO PA

U.S. TIE CONTACT INFORMATION

STREET ADDRESS:
HOME PHONE:

WORK PHONE:

CITY:

STATE:

MOBILE PHONE:

EMAIL:

COUNTRY: U.S.A. ZIP CODE:

Has the U.S. Tie filed a RIF before?

Yes:

No:

If YES, please indicate:

How many RIFs the U.S. Tie has previously filed for immediate family members (mother, father, spouse, children, and siblings)? ________________
How many RIFs the U.S. Tie has previously filed for non-immediate family members or friends? _______________

SECTION 2: INFORMATION ABOUT THE REFUGEE FAMILY

List all family members applying to this program, including the principal applicant (PA), spouse, and any children under the age of 21. Children over 21 years of age or turning 21 within nine months of
filing this form must file a separate RIF, if applying to the program. Children under 18 years of age will only be processed when together with their parent(s). If you need more space, continue on the
RIF Supplemental Page for Section 2.
NAME: LAST, FIRST, MIDDLE

RELATION TO
PRINCIPAL
APPLICANT (PA)
PA

1.

GENDER

MARITAL
STATUS

DATE OF BIRTH

CITY/COUNTRY
OF BIRTH

NATIONALITY

CURRENT
RELIGION

DATE OF
CONVERSION
(IF APPLICABLE)

DOES THE
APPLICANT
SPEAK FARSI?
Y/N

Iran

2.
If spouse is not traveling with #1, see Section 3

3.
4.
5.
6.

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 2: INFORMATION ABOUT THE APPLICANTS (CONTD)

CURRENT CONTACT INFORMATION (IN ENGLISH)
Provide the current contact information for the principal applicant (PA) below. This section must be filled out completely, no fields should be left blank. If a field does not apply, enter N/A.
WHEN DID THE PA START LIVING AT THIS ADDRESS?
NAME OF PRINCIPAL APPLICANT:
(PROVIDE MONTH AND YEAR, IF MOVED or SINCE BIRTH, IF NEVER MOVED)
STREET ADDRESS (STREET, ALLEY, DOOR #):
WHEN DID THE PA START USING THIS NUMBER?
(PROVIDE MONTH AND YEAR)

HOME PHONE: +98

PROVINCE:

CITY:

EMAIL ADDRESS:

POSTAL CODE:

COUNTRY:

WHEN DID THE PA START USING THIS NUMBER?

MOBILE PHONE: +98

(PROVIDE MONTH AND YEAR)

WHEN DID THE PA START USING THIS EMAIL ADDRESS? (PROVIDE MONTH AND YEAR)

SECTION 3: NON-ACCOMPANYING SPOUSE

Is the principal applicants spouse traveling with the principal applicant and listed in Section 2?

Yes:

No:

If NO, please provide details below, including the reason why the spouse is not traveling:

NAME OF NON-ACCOMPANYING SPOUSE: LAST, FIRST, MIDDLE

GENDER

DATE OF BIRTH

CITY/COUNTRY
OF BIRTH

NATIONALITY

CURRENT
RELIGION

DATE OF
CONVERSION
(IF APPLICABLE)

RELATION TO PA

Spouse

SECTION 4: PARENTS OF PRINCIPAL APPLICANT

List both parents of the principal applicant, including those deceased.
NAME: LAST, FIRST, MIDDLE

RELATION

NO. OF
MARITAL
STATUS MARRIAGES

DATE
OF BIRTH

COUNTRY
NATIONALITY RELIGION
OF BIRTH

IMMIGRATION
PREVIOUS
YEAR OF
CITY/COUNTRY STATUS IN DECEASED
RELIGION
CONVERSION OF RESIDENCE COUNTRY OF
Y/N
(IF APPLICABLE)
RESIDENCE

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 5: CHILDREN OF PRINCIPAL APPLICANT

List ALL children of the principal applicant NOT in Section 2, including those deceased. If you need more space, continue on the RIF Supplemental Page for Section 5.

NAME: LAST, FIRST, MIDDLE

GENDER

NO. OF
MARITAL
STATUS MARRIAGES

DATE
OF BIRTH

COUNTRY
OF BIRTH

NATIONALITY RELIGION

CITY/COUNTRY
OF RESIDENCE

RELATION
IMMIGRATION
(CHILD,
DECEASED
STATUS IN
STEP-CHILD,
Y/N
COUNTRY
ADOPTED,
OF RESIDENCE
ETC.)

SECTION 6: SIBLINGS OF PRINCIPAL APPLICANT

List ALL siblings of the principal applicant, including those deceased. If you need more space, continue on the RIF Supplemental Page for Section 6.

NAME: LAST, FIRST, MIDDLE

RIF July 2014

GENDER

NO. OF
MARITAL
STATUS MARRIAGES

DATE
OF BIRTH

COUNTRY
OF BIRTH

NATIONALITY RELIGION

CITY/COUNTRY
OF RESIDENCE

IMMIGRATION
DECEASED
STATUS IN
Y/N
COUNTRY
OF RESIDENCE

RELATION

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 7: EMPLOYMENT
List a complete employment history for all applicants in Section 2 who are age 18 or older. Employment histories should start with the first job held after the age of 17. If you need more space,
continue on the RIF Supplemental Page for Section 7.
NAME: LAST, FIRST, MIDDLE

NAME OF COMPANY/
ORGANIZATION

TITLE

COMPANY/ORG.
CITY, STATE, COUNTRY

START DATE

END DATE

Number of Supplemental Pages used:

SECTION 8: MILITARY SERVICE

List military service details for all male applicants in Section 2 who are age 18 or older. If none, please indicate if the applicant is exempted or studying.
NAME: LAST, FIRST, MIDDLE

START DATE

END DATE

BRANCH/UNIT

COUNTRY

RANK ATTAINED

ATTENDING UNIVERSITY
OR EXEMPTED

If the applicant has been exempted from the military, please provide the applicants name and the reason for the exemption:

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 9: TRAVEL
Have any of the applicants listed in Section 2 ever traveled outside of Iran for any length of time during their entire life?

Yes:

No:

If YES, please provide details below regarding all travel for all family members on this application. A complete copy of the travel documents or visas used for the travel must be included with this
application. If you need more space, continue on the RIF Supplemental Page for Section 9.

NAME: LAST, FIRST, MIDDLE

COUNTRY VISITED
OR RESIDED

DATE OF
DEPARTURE
FROM IRAN

DATE OF
RETURN
TO IRAN

DURATION OF
TRIP OR STAY

REASONS
FOR TRAVEL

REASONS FOR
RETURN TO IRAN

COPY OF TRAVEL
DOCUMENT
INCLUDED WITH
APPLICATION? Y/N*
IF NO, SEE BELOW.

Number of Supplemental Pages used:

*If copies of the travel documents are not included in this application, please explain why:

If you are submitting an update to this section, please provide the date updated: ______________

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 10: VISAS AND LEGAL PERMANENT RESIDENCE OUTSIDE OF IRAN

UNITED STATES
Have any of the applicants listed in Section 2 ever applied for a VISA to the U.S. or Legal Permanent Residence (green card) in the U.S.?

Yes:

No:

If YES, please provide details below:

NAME: LAST, FIRST, MIDDLE

WHERE
APPLIED

TYPE OF
APPLICATION
VISA/
RESIDENCY

DATE
APPLIED
Denied
Visas
Only

OUTCOME
(IN
PROGRESS/
GRANTED/
DENIED)

ISSUE
DATE

EXPIRATION
DATE

TRAVEL/RESIDE
IN THE U.S.?
Y/N

DATE
ENTERED
U.S.

DATE
DEPARTED
U.S.

COPY OF TRAVEL
DOCUMENT
INCLUDED WITH
APPLICATION? Y/N*
IF NO, SEE BELOW.

*If copies of the travel documents are not included in this application, please explain why:

ANY OTHER COUNTRIES

Have any of the applicants listed in Section 2 ever applied for a VISA to any other countries or legal residence in any other countries? This section includes Armenian Special Residency Permits.

Yes:

No:

If YES, please provide details on next page.

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 10: VISAS AND LEGAL PERMANENT RESIDENCE OUTSIDE OF IRAN (CONT)
If YES, please provide details below:

NAME: LAST, FIRST, MIDDLE

TYPE OF
APPLICATION
VISA/
RESIDENCY

COUNTRY
ISSUING
VISA/
RESIDENCY

DATE
APPLIED
Denied
Visas
Only

OUTCOME
(GRANTED/
DENIED)

ISSUE
DATE

EXPIRATION
DATE

DID YOU
TRAVEL/RESIDE
IN THE
COUNTRY? Y/N

DATE
ENTERED
COUNTRY

DATE
DEPARTED
COUNTRY

COPY OF TRAVEL
DOCUMENT
INCLUDED WITH
APPLICATION?
Y/N*
IF NO, SEE BELOW.

*If copies of the travel documents are not included in this application, please explain why:

SECTION 11: CITIZENSHIP OUTSIDE OF IRAN

Have any of the applicants listed in Section 2 ever held citizenship from a country other than Iran at any point in their entire life?
Yes:

No:

If YES, please list the applicants name and the name of the country or countries (other than Iran) where the applicant has/had citizenship.

Provide passport details in SECTION 12: PASSPORTS (next page).

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 12: PASSPORTS

CURRENT PASSPORTS

List ALL current passports held by all applicants listed in Section 2. If you need more space, continue on the RIF Supplemental Page for Section 12, Current Passports.
NAME: LAST, FIRST, MIDDLE

RELATION TO
PRINCIPAL
APPLICANT

PASSPORT NUMBER

ISSUING COUNTRY

ISSUE
DATE

EXPIRATION
DATE

SPOUSE/CHILDREN
LISTED IN PASSPORT?
IF YES, PLEASE INDICATE WHO

COPY OF PASSPORT
IN APPLICATION? Y/N
IF NO, PLEASE
EXPLAIN BELOW

PA

If copies of current passports are not included in this application, please explain why:

EXPIRED PASSPORTS

List ALL expired passports ever held by all applicants listed in Section 2. If you need more space, continue on the RIF Supplemental Page for Section 12, Expired Passports.
NAME: LAST, FIRST, MIDDLE

RELATION TO
PRINCIPAL
APPLICANT

PASSPORT NUMBER

ISSUING COUNTRY

ISSUE
DATE

EXPIRATION
DATE

SPOUSE/CHILDREN
LISTED IN PASSPORT?
IF YES, PLEASE INDICATE WHO

COPY OF PASSPORT
IN APPLICATION? Y/N
IF NO, PLEASE
EXPLAIN BELOW

PA

If copies of expired passports are not included in this application, please explain why:

RIF July 2014

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 13: REFUGEE OR OTHER LEGAL STATUS

Have any of the applicants listed in Section 2 ever applied for REFUGEE or ASYLUM or IMMIGRATION status to any country?

Yes:

No:

If YES, list the country/countries applied to and the date applied:

Is the application currently in progress?

Yes:

No:

If the application is no longer in progress, what was the outcome?

Are copies of the supporting documents included with this application?

Yes:

No:

If copies are not included in the application, please explain why:

SECTION 14: CONVICTIONS (THIS DOES NOT INCLUDE VIOLATIONS OF SHARIA LAW)
Have any of the applicants listed in Section 2 on this form ever been convicted of a crime in a court of law in Iran or any other country?

Yes:

No:

If YES, please provide details of the conviction and sentence, including the nature, date, and location of the violation, as well as the date of conviction.

Are copies of the supporting documents included with this application?

Yes:

No:

If copies are not included in the application, please explain why:

RIF July 2014

10

REFUGEE INFORMATION FORM

NAME OF PRINCIPAL APPLICANT:

DATE OF BIRTH :

SECTION 15: MEDICAL CONDITIONS

All medical conditions must be reported for anyone listed in Section 2 of this form. This includes conditions that they have been treated for in the past and/or conditions that they are treated for
currently. Please specify the medication they are taking, including the dosage and how often the medication is taken, as well as any special care (such as specialist doctor visits, therapy or
treatments, etc.) that they may need while in Austria. Include a medical report from a qualified physician that contains this information as noted in the Application Checklist.
Be advised that if an applicant is unable to care for themselves, the U.S. Tie must arrange for care throughout the applicant's stay in Austria. All costs of medical treatment in Austria are the
responsibility of the applicants and the U.S. Tie.
FAMILY MEMBER NAME: LAST, FIRST, MIDDLE

MEDICAL CONDITION

DATE OF
CONDITION

MEDICATION DOSAGE AND HOW OFTEN TAKEN

SPECIAL CARE NEEDED

______________________________________________________________________________________________________________________________________________________________
I hereby confirm that all information on this form and all documentation submitted in connection with this application is true and complete to the best of my knowledge. I further affirm that:

I have a genuine personal relationship to the applicants on whose behalf I submit this application.

Neither I nor any of my family or associates will profit from the submission of this application through any monetary or material compensation, reward, or gift.

This application is submitted with the sole and genuine intent of assisting the applicants to flee persecution and being reunited with them in the U.S.

I will convey to the applicant all information regarding processing, including, but not limited to: processing procedures, appointment times, acceptance into the program, and the
necessary documents.

I understand that it is my responsibility to ensure that the applicants listed in this application have adequate financial resources, food, clothing, shelter, and access to medical care during
their stay in Vienna for a period of no less than six months.

I further understand that providing false information on this form may have negative consequences on other immigration benefits for which I or the applicants may be eligible.
: .
.

. :

.
.

U.S. Tie Signature:

Date:

Local Resettlement Agency Representative Signature:

Date:

HQ Resettlement Agency Representative Signature:

Date:

RIF July 2014

11