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Fillable Printable Form I-821

Fillable Printable Form I-821

Form I-821

Form I-821

Form I-821 12/23/16 Y
For USCIS Use Only
Application for Temporary Protected Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-821
OMB No. 1615-0043
Expires 02/28/2017
START HERE - Type or print in black ink.
Part 1. Type of Application (check one)
Part 2. Information About You
This is my re-registration application for TPS. I was
previously granted TPS.
1.b.
This is my initial (first time) application for
Temporary Protected Status (TPS). I was not
previously granted TPS.
1.a.
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
For USCIS Use Only
Action Block
Remarks
Receipt
Resubmitted:
Returned:
Sent:
Received:
Case ID:
A-Number:
Relocated:
Yes, I am requesting an Employment Authorization
Document (EAD), and I am filing Form I-765,
Application for Employment Authorization, together
with my Form I-821.
2.a.
No, I am not currently requesting employment
authorization, but I am filing Form I-765 (as required
for administrative purposes) together with my Form
I-821.
2.b.
2.e.
State
2.f.
ZIP Code
U.S. Mailing Address
Street Number
and Name
2.b.
2.c.
Apt.Flr.Ste.
City or Town2.d.
Are you also filing a request for employment authorization?
Is your current mailing address the same as your physical
address?
2.g.
NoYes
If you answered "No" to Item Number 2.g., please provide
your physical address below.
InCare Of Name
2.a.
U.S. Physical Address
3.d.
State
3.e.
ZIP Code
Street Number
and Name
3.a.
3.b.
Apt.Flr.Ste.
City or Town3.c.
Page 1 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Part 2. Information About You (continued)
Alien Registration Number (A-Number) (if any)4.
A-
USCIS ELIS Account Number (if any)5.
7.Date of Birth (mm/dd/yyyy)
U.S. Social Security Number (if any)
6.
Other Information
City/Town/Village
ofBirth
9.
8.
MaleFemaleGender
11.Country of Residence
Country of Birth 10.
Race (Select allapplicable boxes)
16.
Height18.
Weight
FeetInches
17.
Pounds
Blue
Green
Hazel
Pink
Unknown/Other
Maroon
Gray
Brown
19.
Eye Color (Select only one box)
Hair Color (Select only one box)
20.
Black
BrownRed
White
Unknown/
Other
Sandy
Gray
BlondBald (No hair)
(mm/dd/yyyy)
Date of last entry into the United States
21.
U.S. Entry Information
Immigration status when you last entered the United States
(e.g., visitor, student, entered without inspection (EWI))
22.
Marital Status
MarriedWidowedSingleDivorced
13.
Country of Citizenship/Nationality (if any)12.
Other Names Used (if any, including maiden name)
14.a.Family Name
(Last Name)
14.b.Given Name
(First Name)
14.c.
Middle Name
Other Dates of Birth Used (if any)
(mm/dd/yyyy)Date of Birth15.a.
(mm/dd/yyyy)Date of Birth15.b.
24.a.
Place of last entry into the United States
City or Town
State
U.S. Port of Entry (if any)
24.b.
24.c.
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select onlyone box)
23.
White
Asian
Black or African American
American Indian or Alaska Native
Black
Native Hawaiian or Other Pacific Islander
Page 2 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Passport Number (if any)25.c.
Travel Document Number (if any)25.d.
25.e.
Country of Issuance for Passport or Travel Document
25.f.Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
26.
Current immigration status (e.g., visitor, student, visa
overstay, EWI)
Your Current Immigration Status
Are you now or were you ever in immigration
proceedings?
Exclusion
Removal/Deportation
Rescission
28.a.
28.b.
28.c.
28.d.
Type of proceedings (Select onlyone box):
If you answered "Yes" to Item Number 27., provide the
following information.
27.
YesNo
Location where your proceedings were held (or are
currently being held)
29.
Mailing Address of Spouse
Middle Name
3.c.
Given Name
(First Name)
3.b.
Street Number
and Name
4.a.
ZIP Code
4.e.
State
4.d.
City or Town4.c.
Country (if any)4.h.
4.g.
Postal Code (if any)
4.f.
4.b.Apt.
Flr.Ste.
Family Name
(Last Name)
3.a.
USCIS ELIS Account Number (if any)1.
Provide the following information about your spouse
(if married).
Part 3. Information About Your Spouse and
Children (if any)
Province (if any)
Part 2. Information About You (continued)
Alien Registration Number (A-Number) (if any)2.
A-
25.a.Arrival-Departure Record (Form I-94) (if any)
25.b.
(mm/dd/yyyy)
Date authorized period of stay in the United States
expired or will expire (as shown on Form I-94 or I-95)
(mm/dd/yyyy)
Dates for your proceedings (If your proceedings are
ongoing, leave the "To" date blank)
30.
(mm/dd/yyyy)
From:
To:
I am no longer in immigration proceedings, but I was
in
Federal court proceedings regarding immigration
issues.
Page 3 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
8.f.Date of Birth(mm/dd/yyyy)
8.c.
8.d.
8.e.
8.g.
USCIS ELIS Account Number (if any)8.a.
Provide the following information about each of your children
(if any).
Children (if any)
Child 1
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
Part 3. Information About Your Spouse and
Children (continued)
Alien Registration Number (A-Number) (if any)8.b.
A-
9.e.
9.d.
9.c.
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
(mm/dd/yyyy)Date of Birth9.f.
Street Number
and Name
ZIP CodeState
City or Town
Country (if any)
Postal Code (if any)
Apt.
Flr.Ste.
Province (if any)
8.h.
8.i.
8.j.8.k.
8.l.
8.m.
8.n.
9.g.
Street Number
and Name
ZIP CodeState
City or Town
Country (if any)
Postal Code (if any)
Apt.
Flr.Ste.
Province (if any)
9.h.
9.i.
9.j.9.k.
9.l.
9.m.
9.n.
10.e.
Date of Birth(mm/dd/yyyy)
10.c.
10.d.
10.f.
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
Child 3
USCIS ELIS Account Number (if any)10.a.
Alien Registration Number (A-Number) (if any)10.b.
A-
Child 2
USCIS ELIS Account Number (if any)9.a.
Alien Registration Number (A-Number) (if any)9.b.
A-
Place of Present Marriage7.
6.Date of Present
Marriage
(mm/dd/yyyy)
Other Information About Spouse
(mm/dd/yyyy)
Your Spouse's
Date of Birth
5.
Page 4 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
11.f.
11.d.
11.c.
(mm/dd/yyyy)
Date of Birth
11.e.
Child 4
USCIS ELIS Account Number (if any)11.a.
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
Alien Registration Number (A-Number) (if any)11.b.
A-
Part 3. Information About Your Spouse and
Children (continued)
Child 3 (continued)
10.g.
Street Number
and Name
ZIP CodeState
City or Town
Country (if any)
Postal Code (if any)
Apt.
Flr.Ste.
Province (if any)
10.h.
10.i.
10.j.10.k.
10.l.
10.m.
10.n.
12.e.
Date of Birth(mm/dd/yyyy)
12.c.
12.d.
12.f.
Child 5
USCIS ELIS Account Number (if any)12.a.
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
Alien Registration Number (A-Number) (if any)12.b.
A-
11.g.
Street Number
and Name
ZIP CodeState
City or Town
Country (if any)
Postal Code (if any)
Apt.
Flr.Ste.
Province (if any)
11.h.
11.i.
11.j.11.k.
11.l.
11.m.
11.n.
12.g.
Street Number
and Name
ZIP CodeState
City or Town
Country (if any)
Postal Code (if any)
Apt.
Flr.Ste.
Province (if any)
12.h.
12.i.
12.j.12.k.
12.l.
12.m.
12.n.
Page 5 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Any particularly serious crime committed either in or
outside the United States?
NoYes
Any misdemeanor(s) committed in the United States?2.b.
NoYes
2.c.
No
Yes
Have you EVER ordered, incited, assisted, or otherwise
participated in the persecution of any person on account
of race, religion, nationality, membership in a particular
social group, or political opinion?
3.a.
Have you EVER committed serious nonpolitical crimes
outside of the United States prior to your arrival in the
United States?
3.b.
YesNo
Part 4. Eligibility Standards
1.b.I entered the United States on the following date, and
have resided in the United States since that time.
I am a national of (or an alien having no nationality who
last habitually resided in the country of):
Provide the following information:
(mm/dd/yyyy)
1.a.
2.a.Any felony committed in the United States?
Have you EVER been convicted of:
NoYes
NoYes
Have you EVER resided in any country(s) other than the
one listed in Item Number 1.a.?
1.c.
If you answered "Yes" to Item Number 1.c., and you resided in
more than one country prior to entering the United States,
provide information about the last country in which you resided
in the spaces below. For any additional countries, attach a
separate sheet(s) of paper. Write your full name and A-Number
(if any) at the top of each sheet; indicate the Page Number,
Part Number, and Item Number to which your answer refers
(e.g., Page 6, Part 4., Item Number 1.d.); and date and sign
each sheet.
1.d.
Name of another country in which you resided (if any)
Your immigration status in the other country (e.g., citizen,
permanent resident, refugee, asylee, visitor, temporary
resident)
(mm/dd/yyyy)
Dates that you resided in the other country1.e.
(mm/dd/yyyy)
1.f.
To be eligible for TPS, you must be admissible as an
immigrant to the United States, with certain exceptions.
If any of the questions beginning below and continuing through
the end of Part 4. apply to you, describe the circumstances and
include a full explanation on a separate sheet(s) of paper. Write
your full name and A-Number (if any) at the top of each sheet;
indicate the Page Number, Part Number, and Item Number to
which your answer refers, (e.g., Page 6, Part 4., Item Number
2.b.); and date and sign each sheet.
NoYes
Have you EVER or are you NOW engaged in activities
that could be reasonable grounds for concluding that you
are a danger to the security of the United States?
3.c.
A violation of any law relating to a controlled substance
as defined in section 102 of the Controlled Substances
Act?
4.b.
YesNo
A crime (other than a purely political offense)?4.a.
Have you EVER been convicted of or have you EVER
committed acts which constitute the essential elements of:
NoYes
No
Yes
A conspiracy to violate any law relating to a controlled
substance as defined in section 102 of the Controlled
Substances Act?
4.c.
Have you EVER been convicted of two or more criminal
offenses (other than purely political offenses) for which
you received sentences to confinement that, when
combined, total 5 years or more?
5.a.
NoYes
If you were EVER arrested, provide the disposition (outcome)
for all arrests. (For example, "case dismissed" from the
appropriate authority.) For information about waivers concerning
the grounds of inadmissibility, see the NOTE at the end of Part 4.
To:
From:
Page 6 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Part 4. Eligibility Standards (continued)
7.d.
7.c.
7.b.
Have you EVER been or are you NOW a member of the
Communist or other totalitarian party, except when
membership was involuntary?
YesNo
Have you EVER participated in Nazi persecution or
genocide?
NoYes
Have you EVER or are you NOW engaged in or plan to
engage in activities in the United States that would have
potentially serious adverse foreign policy consequences
for the United States?
YesNo
Have you EVER been arrested, cited, charged, indicted,
fined, or imprisoned for breaking or violating any law or
ordinance, excluding minor traffic violations?
8.a.
NoYes
Have you EVER been the beneficiary of a pardon,
amnesty, rehabilitation decree, other act of clemency, or
similar action?
8.b.
NoYes
NoYes
Have you EVER committed a serious criminal offense in
the United States and asserted immunity from
prosecution?
9.
Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
5.c.
NoYes
5.d.Are you the spouse or child of an alien who unlawfully
trafficked in any controlled substance?
NoYes
Are you the spouse or child of an alien who assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
5.e.
NoYes
Within the previous 5 years, have you EVER obtained
any financial or other benefit from the unlawful activity
of your spouse (including former spouses) or parents, and
you knew, or reasonably should have known, that the
financial or other benefit was the product of such illicit
activity?
5.f.
NoYes
Any activity to violate any law of the United States
relating to espionage or sabotage?
6.a.
Have you EVER engaged, or do you plan to engage, solely,
principally, or incidentally, in any of the following:
NoYes
Any activity to violate or evade any law prohibiting the
export from the United States of goods, technology, or
sensitive information?
6.b.
NoYes
Any other unlawful activity in the United States?6.c.
NoYes
Any activity in which a purpose is the opposition to, or the
control or overthrow of, the Government of the United
States by force, violence, or other unlawful means,
including but not limited to, participating in such activities,
giving support to others involved in such activities, or being
a member or representative of a terrorist organization?
6.d.
NoYes
10.a.Have you EVER, within the past 10 years, or are you
NOW engaged in prostitution or procurement of
prostitution?
YesNo
Have you EVER, within the past 10 years (either directly
or indirectly) procured or attempted to procure or import,
prostitutes or persons for the purpose of prostitution?
10.b.
NoYes
Have you EVER, within the past 10 years, received, in
whole or in part, the proceeds of prostitution?
10.c.
NoYes
Have you EVER been or do you intend to be involved in
any other commercial vice?
11.
YesNo
Have you EVER been ordered removed, and been
deported from the United States?
12.a.
NoYes
Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
NoYes
5.b.
7.a.Have you EVER or are you NOW engaged in terrorist
activities?
NoYes
Page 7 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Are you NOW subject to a final order for violation of
section 274C (producing and/or using false
documentation to unlawfully satisfy a requirement of the
Immigration and Nationality Act)?
Are you NOW the guardian of, and are you
accompanying, another alien who has been found to be
inadmissible and who has been certified by a medical
examiner to be helpless due to sickness, physical or
mental disability, or infancy?
Part 4. Eligibility Standards (continued)
NoYes
Do you NOW practice polygamy?
17.
18.
YesNo
19.
YesNo
NoYes
Have you EVER detained, retained, or withheld the
custody of a child having a lawful claim to U.S.
citizenship, outside the United States, from a U.S. citizen
granted custody?
20.
Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:
NoYes21.a.Acts involving torture or genocide?
If you answered "Yes" to either Item Number 12.a. or
12.b. above, have you re-entered the United States
unlawfully at any time after you were deported or you
voluntarily departed?
12.c.
NoYes
If you answered "Yes" to Item Number 12.c. above, has
your prior order of removal been reinstated by DHS?
12.d.
NoYesDo not know
Have you EVER failed to attend or remain in attendance
at any immigration proceedings to determine your
admissibility or deportability?
12.e.
NoYes
Have you EVER, by fraud or willfully misrepresenting
a material fact, sought to obtain a visa or other
documentation, admission to the United States, or any
other immigration benefit?
12.f.
NoYes
Killing any person?21.b.
YesNo
14.a.
Do you NOW have or have you EVER had a physical or
mental disorder and behavior (or a history of behavior
that is likely to recur) associated with the disorder which
has posed or may pose a threat to the property, safety, or
welfare of yourself or others?
14.b.
Do you NOW have a communicable disease of public
health significance?
Have you EVER assisted any other person to enter the
United States in violation of the law?
13.
YesNo
YesNo
YesNo
NoYes
Are you NOW or have you EVER been a drug abuser or
drug addict?
14.c.
No
Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
21.d.
YesNo
21.e.
Yes
21.c.
Limiting or denying any person's ability to exercise
religious beliefs?
Intentionally and severely injuring any person?
YesNo
NoYes
Have you EVER entered the United States as a stowaway?15.
Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
defense unit, vigilante unit, rebel group, guerrilla group,
militia, or insurgent organization?
Have you EVER:
YesNo
22.a.
Served or worked in any prison, jail, prison camp,
detention facility, labor camp, or any other situation that
involved detaining persons?
22.b.
YesNo
16.Did the former Immigration and Naturalization Service
(INS) EVER impose, or has DHS EVER imposed, civil
monetary penalties on you for producing or using false
documentation to obtain an immigration benefit?
YesNo
Have you EVER voluntarily departed the United States
under an order of removal?
12.b.
NoYes
Page 8 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Are you NOW or have you EVER engaged in money
laundering as described in section 1956 or 1957 of Title
18, United States Code?
Part 4. Eligibility Standards (continued)
29.e.
NoYes
30.a.
NoYes
30.b.
NoYes
Have you EVER been responsible for or directly carried
out particularly severe violations of religious freedom, as
defined in section 3 of the International Religious Freedom
Act of 1998 (22 U.S.C. section 6402) while serving as a
foreign government official?
31.
NoYes
NOTE ABOUT WAIVERS: A TPS applicant must be
admissible under the applicable grounds in section 212 of the
Immigration and Nationality Act (INA). USCIS may grant a
discretionary waiver for some, but not all, of the applicable
inadmissibility grounds based on humanitarian, family unity, or
public interest reasons.
Are you NOW or have you EVER been a knowing aider,
abettor, assister, conspirator, or colluder with others in
money laundering?
Within the previous 5 years, have you EVER obtained
any financial or other benefit from the human trafficking
activity of your spouse (including former spouses) or
parents, and knew, or reasonably should have known, that
the financial or other benefit was the product of such
illicit activity?
Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any
kind in which you or other persons used any type of
weapon against any person or threatened to do so?
YesNo
23.
Have you EVER received any type of military,
paramilitary, or weapons training?
25.
YesNo
Have you EVER unlawfully voted in a United States
Federal, state, or local election?
26.
NoYes
Have you EVER assisted with or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
24.
YesNo
Have you EVER claimed to be a United States citizen (in
writing or in any other way)?
27.
NoYes
NoYes
28.a.
29.a.
NoYes
29.b.
NoYes
Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded with a human trafficker?
Have you EVER committed or conspired to commit
human trafficking offenses, as defined in the section 103
of the Victims of Trafficking and Violence Protection Act
of 2000, in the United States or outside the United States?
Has an immigration judge or the Board of Immigration
Appeals EVER determined that you filed a frivolous
asylum application in the past?
32.
NoYes
If you answered “Yes” to certain Item Numbers in Part 4., you
may be eligible for a waiver of some of the grounds of
inadmissibility. Please see the General Requirements section
of Form I-821 instructions for further information.
NoYes
29.c.Are you NOW the spouse or child of an alien who
committed or conspired to commit human trafficking
offenses?
Form I-601, Application for Waiver of Grounds of
Inadmissibility, is the application used to request a waiver.
Please read the special instructions related to TPS applicants
on Form I-601. The form is available at local USCIS offices,
on our Web site at www.uscis.gov/I-601, or by calling the
USCIS toll-free forms line at 1-800-870-3676. For TDD (deaf
or hard of hearing) call: 1-800-767-1833.
29.d.
NoYes
Are you NOW the spouse or child of, or are you yourself,
an alien who knowingly aided, abetted, assisted,
conspired, or colluded with a human trafficker?
Have you EVER recruited, enlisted, conscripted, or used
any person under age 15 to serve in or help an armed
force or group?
NoYes
28.b.
Have you EVER used any person under age 15 to take
part in hostilities or to help or provide services to people
in combat?
Page 9 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
Part 6. Contact Information, Certification, and
Signature of the Interpreter
Part 5. Statement, Certification, Signature, and
Contact Information of the Applicant
I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to each question.
1.b.
The interpreter named below has read to me each and
every question and instruction on this form, as well
as my answer to each question, in
1.a.
a language in which I am fluent. I understand each
and every question and instruction on this form as
translated to me by my interpreter, and have provided
true and correct responses in the language indicated
above.
,
2.I have requested the services of and consented to
who isis not
representative, preparing this form for me.
an attorney or accredited
(mm/dd/yyyy)Date of Signature3.b.
Applicant's Signature3.a.
I furthermore authorize release of information contained in this
form, supporting documents, and my USCIS records to other
entities and persons where necessary for the administration of
U.S. immigration laws.
Applicant Certification
I certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct. Copies
of documents submitted are exact photocopies of unaltered
original documents, and I understand that I may be required to
submit original documents to U.S. Citizenship and Immigration
Services (USCIS) at a later date. Furthermore, I authorize the
release of any information from my records that USCIS may
need to determine my eligibility for the benefit that I seek.
Applicant's E-mail Address6.
Applicant's Mobile Telephone Number
()
-
5.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Provide the following information concerning the interpreter:
3.h.
Interpreter's Mailing Address
3.c.City or Town
3.d.State3.e.ZIP Code
3.f.
3.g.
Province (if any)
Street Number
and Name
3.a.
Country (if any)
3.b.Apt.
Flr.Ste.
Interpreter's Contact Information
4.Interpreter's Daytime Telephone Number
Interpreter's E-mail Address
()
-
5.
Applicant's Daytime Telephone Number4.
()
-
Postal Code (if any)
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
Page 10 of 11
Form I-821 12/23/16 Y
For USCIS Use Only
3.h.
3.f.
Postal Code (if any)3.g.
Country (if any)
Preparer's Business or Organization Name2.
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 7.Contact Information, Declaration, and
Signature of the Person Preparing this
Application, If Other than the Applicant
(mm/dd/yyyy)Date of Signature6.b.
Interpreter's Signature6.a.
Interpreter Certification
I certify that:
I am not an attorney or accredited representative but
have prepared this form on behalf of the applicant
and with the applicant's consent.
I am an attorney or accredited representative and my
representation of the applicant in this case
(choose one) extends does not extend
7.a.
7.b.
beyond the preparation of this form.
Preparer's Contact Information
4.Preparer's Daytime Telephone Number
6.Preparer's E-mail Address
()
-
5.Preparer's Fax Number
()
-
Preparer's Mailing Address
3.c.City or Town
3.d.State3.e.ZIP Code
Street Number
and Name
3.a.
3.b.Apt.
Flr.Ste.
8.a. Preparer's Signature
8.b.Date of Signature(mm/dd/yyyy)
Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the applicant. I completed the
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with each
and every answer provided for each question on the form and,
when required, supplied additional information to respond to a
question on the form.
I have read to this applicant each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 5,. Item Number 1.b.; and
The applicant has informed me that he or she understands each
and every instruction and question on the form, as well as the
answer to each question.
is the same language provided in Part 5., Item Number 1.b.;
I am fluent in English and which
Province (if any)
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