Form I-821 Application for Temporary Protected Status

OMB No. 1615-0043; Exp. 07/31/07

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-821, Application for
Temporary Protected Status

START HERE - Please type or print in black ink.
Part 1. Type of application. (check one)

Returned

For USCIS Use Only

a.

This is my first application to register for Temporary Protected Status (TPS).

b.

This is my application for re-registration or renewal of temporary treatment
benefits. I have previously been granted TPS or temporary treatment benefits. I
have maintained and continue to maintain eligibility for TPS.

Part 2.

Information about you.

Family Name (Last Name)

Given Name (First Name)

Full Middle Name

U.S. Mailing Address: (Street Number and Name)

Apt. #

Date
Date
Resubmitted
Date
Date
Reloc Sent
Date

C/O: (In Care Of)
Town/City

State

Date
Reloc Rec'd

County

Zip Code

Date

Date of Birth (mm/dd/yyyy)

Gender

Date
Male

Female

Place of Birth (Town or City)

State/Country

Country of Residence

Country of Citizenship/Nationality

Marital Status
Single
Married
Divorced
Other Names Used (including maiden name)
Date of Entry Into the U.S. (mm/dd/yyyy)

Receipt

Widowed

Applicant
Interviewed
on
Case ID #:
A #:
Remarks

Place of Entry Into the U.S.

Manner of Arrival (Visitor, student, stowaway, without inspection, etc.)
Arrival/Departure Record
(I-94) Number
Your Current Immigration Status:
In Status (state nonimmigrant

Date authorized stay expired/or will expire,
as shown on Form I-94 or I-95 (mm/dd/yyyy)

classification, e.g. F-1, etc.)

Out of Status (state nonimmigrant violation,
e.g., overstay student, EWI etc.)

Alien Registration Number (A#) (if any)

U.S. Social Security Number (if any)

Are you now or have you ever been under immigration proceedings?
Yes
No
If you answered "Yes" to the above question, provide the following information.
Type of proceedings:
Exclusion
Removal/Deportation
Recission
Judicial Proceedings
Location of Proceedings

Date of Proceedings (mm/dd/yyyy)

Action Block

To Be Completed by
Attorney or Representative, if any.
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #
Form I-821 (Rev. 07/30/07)Y

Part 3.

Information about your spouse and children. (if any)

1. Provide the following information about your spouse (if married).
Last Name of Spouse
First Name

Middle Name

Address (Street Number and Name)
Town/City

State/Province

Your Spouse's Birth Date (mm/dd/yyyy)
Name of Prior Husbands/Wives

Apt #
Country

Zip/Postal Code

Date and Place of Present Marriage
Date(s) Marriage(s) Ended (mm/dd/yyyy)

2. List the names, ages and current residence of children (if any).
Name (First/Middle/Last)

Part 4.

Date of Birth (mm/dd/yyyy

Residence

Eligibility standards.

1. Provide the following information:
I am a national of, or an alien having no nationality, who last habitually resided in the foreign state of:
I entered the United States on the following date (provide month/day/year), and have resided in the United States since that time.
2. To be eligible for Temporary Protected Status, you must be admissible as an immigrant to the United States, with certain
exceptions.
If any of the questions beginning below on this page and continuing on Page 3 apply to you, number which one(s) in the box(es):
(for example, 2k for Have you entered the United States as a stowaway;) and include a full explanation on a separate sheet(s) of
paper. Use the number 2 before each letter referring to the specific question (2a, 2b, etc.).
If you were ever arrested, provide the disposition (outcome) of the arrest. For example, "case dismissed" from the appropriate
authority.
NOTE: For information about waivers concerning the grounds of inadmissibility, see Page 3.

2a. Have you been convicted of any felony or two or more misdemeanors committed in the United States;
2b. (i) Have you 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;
(ii) Have you been convicted by a final judgment of a particularly serious crime, constituting a danger to the community of the
United States (an alien convicted of an aggravated felony is considered to have committed a particularly serious crime);
(iii) Have you committed a serious nonpolitical crime outside of the United States prior to your arrival in the United States; or
(iv) Have you engaged in or are you still engaged in activities that could be reasonable grounds for concluding that you are a
danger to the security of the United States?
Form I-821 (Rev. 07/30/07)Y Page 2

Part 4.

Eligibility standards.

(Continued)

2c. (i) Have you been convicted of, or have you committed acts which constitute the essential elements of a crime (other than a
purely political offense) or a violation of or a conspiracy to violate any law relating to a controlled substance as defined in
Section 102 of the Controlled Substance Act;
(ii) Have you been convicted of two or more offenses (other than purely political offenses) for which the aggregate sentences
to confinement actually imposed were five years or more;
(iii) Have you trafficked in or do you continue to traffic in any controlled substance or are or have been a knowing assister,
abettor, conspirator, or colluder with others in the illicit trafficking of any controlled substance;
(iv) Have you engaged or do you continue to engage solely, principally, or incidentally in any activity related to espionage or
sabotage or violate any law involving the export of goods, technology, or sensitive information, any other unlawful activity, or
any activity the purpose of which is in opposition, or the control, or overthrow of the government of the United States;
(v) Have you engaged in or do you continue to engage in terrorist activities;
(vi) Have you engaged in or do you continue to engage or plan to engage in activities in the United States that would have
potentially serious adverse foreign policy consequences for the United States;
(vii) Have you been or do you continue to be a member of the Communist or other totalitarian party, except when membership
was involuntary; and
(viii) Have you participated in Nazi persecution or genocide;
2d. Have you been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding
traffic violations, or been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action;
2e. Have you committed a serious criminal offense in the United States and asserted immunity from prosecution;
2f. Have you within the past ten years engaged in prostitution or procurement of prostitution or do you continue to engage in
prostitution or procurement of prostitution;
2g. Have you been or do you intend to be involved in any other commercial vice;
2h. Have you been excluded and deported from the United States within the past year, or have you been deported or removed from
the United States at government expense within the last five years (20 years if you have been convicted of an aggravated
felony);
2i. Have you ever assisted any other person to enter the United States in violation of the law;
2j. (i) Do you have a communicable disease of public health significance.
(ii) Do you have or have you 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;
(iii) Are you now or have you been a drug abuser or drug addict;
2k. Have you entered the United States as a stowaway;
2l. Are you 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);
2m. Do you practice polygamy;
2n. Were you the guardian of, and did you accompany another alien who was ordered excluded and deported (or removed) from the
United States;
2o. Have you detained, retained, or withheld the custody of a child, having a lawful claim to United States citizenship, outside the
United States from a United States citizen granted custody?
NOTE ABOUT WAIVERS: If you placed any of the following numbered references in the boxes on Page 2, you may be eligible
for a waiver of the grounds described in the questions: 2e; 2f; 2g; 2h; 2i; 2j; 2k; 2l; 2m; 2n or 2o. The Form I-601 is the USCIS
application used to request a waiver. The form is available at local USCIS offices, on our website at www.uscis.gov or by calling
the USCIS toll-free forms line at 1-800-870-3676.
Form I-821 (Rev. 07/30/07)Y Page 3