Form I-821 Form I-821 Application for Temporary Protected Status

DRAFT
OMB No. 1615-0043; Exp. 10/31/10
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

Applicant
Interviewed
on
Case ID #:
A #:

Widowed
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. 08/20/10) Y

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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 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 Pages 3, 4, and 5 apply to you, describe the circumstances
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) for all arrests. For example, "case dismissed" from the appropriate
authority. NOTE: For information about waivers concerning the grounds of inadmissibility, see Page 5.
2a. Have you been convicted of any felony or two or more misdemeanors committed in the United States?
Yes

No

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?
Yes

No

(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)?
Yes

No

(iii) Have you committed a serious nonpolitical crime outside of the United States prior to your arrival in the United States?
Yes

No
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(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?
Yes

No

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?
Yes

No

(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?
Yes

No

(iii) Have you trafficked in or do you continue to traffic in any controlled substance, or are you or have you been a knowing
assister, abettor, conspirator, or colluder with others in the illicit trafficking of any controlled substance?
Yes

No

(iv) Have you engaged in 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?
Yes

No

(v) Have you engaged in or do you continue to engage in terrorist activities?
Yes

No

(vi) Have you engaged in or do you continue to engage in or plan to engage in activities in the United States that would have
potentially serious adverse foreign policy consequences for the United States?
Yes

No

(vii) Have you been or do you continue to be a member of the Communist or other totalitarian party, except when membership
was involuntary?
Yes

No

(viii) Have you participated in Nazi persecution or genocide?
Yes

No

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?
No
Yes
2e. Have you committed a serious criminal offense in the United States and asserted immunity from prosecution?
Yes

No

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?
Yes

No

2g. Have you been or do you intend to be involved in any other commercial vice?
Yes

No

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)?
Yes

No

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2i. Have you ever assisted any other person to enter the United States in violation of the law?
Yes

No

2j. (i) Do you have a communicable disease of public health significance?
Yes

No

(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?
Yes

No

(iii) Are you now or have you been a drug abuser or drug addict?
Yes

No

2k. Have you entered the United States as a stowaway?
Yes

No

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)?
Yes

No

2m. Do you practice polygamy?
Yes

No

2n. Were you the guardian of, and did you accompany another alien who was ordered excluded and deported (or removed) from the
United States?
Yes

No

2o. Have you 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?
Yes

No

2p. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
(i) acts involving torture or genocide?
Yes

No

(ii) killing any person?
Yes

No

(iii) intentionally and severely injuring any person?
Yes

No

(iv) engaging in any kind of sexual contact or relations with any person who was being forced or threatened?
Yes

No

(v) limiting or denying any person's ability to exercise religious beliefs?
Yes

No

2q. Have you EVER:
(i) 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?
Yes

No
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(ii) served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved
detaining persons?
Yes

No

2r. 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?
Yes

No

2s. Have you EVER assisted 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?
Yes

No

2t. Have you ever received any type of military, paramilitary, or weapons training?
Yes

No

NOTE ABOUT WAIVERS: 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.

Part 5.

Signature.

Read the information on penalties in the instructions before completing this section. If someone helped you
prepare this petition, he or she must complete Part 6.

Applicant's Statement (check one):
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.
Each and every question and instruction on this form, as well as my answer to each question, has been read to me by the
person named below in
, a language in which I am fluent. I understand each and every question and
instruction on this form, as well as my answer to each question.
YOUR (APPLICANT'S) CERTIFICATION:
I certify, under penalty of perjury under the laws of 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 USCIS at a later date. Furthermore, I authorize the release of any information from my records that U.S.
Citizenship and Immigration Services (USCIS) needs to determine eligibility for the benefits that I am seeking.
Signature

Daytime Phone Number (Area/Country Codes)

Date (mm/dd/yyyy)

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible for

the requested benefit and this petition may be denied.

Form I-821 (Rev. 08/20/10) Y Page 5

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Part 6.

Interpreter's Statement:

Language used:
I certify that I am fluent in English and the above-mentioned language.
I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has understood each and every instruction and question of the form, as
well as the answer to each question.
Signature

Part 7.

Print Your Name

Date (mm/dd/yyyy)

Preparer's Statement:

I declare that I prepared this petition at the request of the above person and it is based on all the information of
which I have knowledge.
Attorney or Representative: In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
Yes
No
Signature

Print Your Name

Firm Name and Address

Part 8.

Date (mm/dd/yyyy)

Daytime Phone Number

Fax Number

Checklist.
Did you answer each question?
Did you sign the Form I-821 application?
Did you submit the required application and biometric services fees, or a written request for waiver of the fees?
Did you submit the necessary documents and photos, if required?
Did you also submit the Form I-765 with the filing fee or a written request for a waiver of the
filing fee (See instructions, items 10, 11 and 12)?

Have you submitted:
The filing fee for this application or a written request for a waiver of the filing fee (see instructions, items 10 and 12)?
Supporting evidence to prove identity, nationality, date of entry, and residence?
Other required supporting documents (photos, etc.) for each application?

Form I-821 (Rev. 08/20/10) Y Page 6