F00040 Special Immigration Request

Instructions:   

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

1)   Please enter all information electronically, starting with your UPI below on this page.

2)   Be aware that the corresponding blocks of information will pop-up after selecting the Relationship of Applicant with Staff Member/Retiree.

3)   Sign in the signature blocks where provided.

4)   Return all pages of this form to HR Operations via (Please select one transmittal format, and  submit only once):    

                   a. E-Mail to hroperations@worldbank.org

                   b. Fax +1(202) 522-7026        

5)   For more information, refer to the checklist.

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 30 Sep 2024

Staff Member's Information / Retiree Information

World Bank Group UPI*

Full Legal Name, as in passport (Last Name, First Name, Middle Name)*

Date of Birth (MM/DD/YYYY):*

Address - Street*

Address - City, State, Postal or Zip Code*

Phone Number*

E-Mail Address*

Applicant's Information

Relationship of Applicant with Staff Member/Retiree*

Full Legal Name, as in passport (Last Name, First Name, Middle Name)*

Date of Birth (MM/DD/YYYY)*

Address - Street*

Address - City, State, Postal or Zip Code*

Phone Number*

E-Mail Address*

Eligibility Review

I believe that I am eligible to be a G-IV Special Immigrant as a retiree on the basis of:

I have been in G-4 or N visa status for at least 15 years while residing and being physically present in the U.S. *

And

I have resided and been physically present in the U.S. in G-4 or N visa status for at least 50% (3.5 years) of the last seven years immediately preceding the date of this application, with the following exceptions:*

From Date*

To Date*

Country*

During my employment with the World Bank Group I have been absent for extended assignments (i.e. LWOP, External Service, Short Term Assignments, Telecommuting, Extended Field Assignments) from the U.S. as follows:

From Date*

To Date*

Country*

Will you also be applying for spouse?*

Spouse Information:

Full Legal Name, as in passport (Last Name, First Name, Middle Name):*

Date of Birth (MM/DD/YYYY)*

Eligibility Review

I believe that I am eligible to be a G-IV Special Immigrant as an unmarried child of an active World Bank Group employee on the basis of:

I have been in G-4 or N visa status for at least 7 years while residing and being physically present in the U.S.*

And

I have resided and been physically present in the U.S. in G-4 or N visa status for at least 50% (3.5 years) of the last seven years immediately preceding the date of this application, with the following exceptions (including school enrollments):*

From Date*

To Date*

Country*

Eligibility Review

I believe that I am eligible to be a G-IV Special Immigrant as a spouse of a deceased World Bank Group employee on the basis of:

I have been in G-4 or N visa status for at least 15 years while residing and being physically present in the U.S.*

And

I have resided and been physically present in the U.S. in G-4 or N visa status for at least 50% (3.5 years) of the last seven years immediately preceding the date of this application, with the following exceptions:*

From Date*

To Date*

Country*

Certification and Signature

The applicant and the Staff Member or Retiree hereby certifies that this application is true to the best of their knowledge and belief. In view of the above information, we hereby request that the World Bank Group review its records and certify eligibility for U.S. permanent residency under the Special Immigration Act.

Signature of Applicant

Date (mm/dd/yyyy)

Signature of Staff Member or Retiree (if different from Applicant)

Date (mm/dd/yyyy)

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.