Application for Deferred Action for Childhood Arrivals

Instructions for Consideration of
Deferred Action for Childhood Arrivals
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-821D
OMB No. 1615-0124
Expires 02/28/2013

What Is the Purpose of This Form?
The purpose of Form I-821D, Consideration of Deferred Action for Childhood Arrivals, is to request that U.S. Citizenship
and Immigration Services (USCIS) consider deferring action, on a case-by-case basis, based on the guidelines described
in the Secretary of Homeland Security's memorandum issued on June 15, 2012, as reflected in the section below entitled
"What is a Childhood Arrival for Purposes of This Form?" (Secretary's memorandum). Deferred action is a
discretionary determination to defer removal of an individual as an act of prosecutorial discretion. Individuals who receive
deferred action will not be placed into removal proceedings or removed from the United States for a specified period of
time, unless the Department of Homeland Security (DHS) chooses to terminate the deferral. See the Secretary's
memorandum at www.uscis.gov/childhoodarrivals.

DRAFT
Not for
Production
03/29/2013

When Should I Use Form I-821D?

Use Form I-821D to request consideration of deferred action under the Secretary's memorandum. Deferred action is a
discretionary determination to defer removal action of an individual as an act of prosecutorial discretion. Deferred action
does not provide lawful status. All individuals filing Form I-821D must also file Form I-765, Application for Employment
Authorization, and Form I-765WS, Form I-765 Worksheet. See section entitled "Initial Evidence" for more information.
NOTE: If U.S. Immigration and Customs Enforcement (ICE) has already deferred action in your case, you may file
Form I-765 and Form I-765WS with USCIS to request work authorization and do not need to file this form. If you are
currently in immigration detention, you may not request consideration of deferred action for childhood arrivals from
USCIS. If you think you meet the guidelines of this process, you should identify yourself to your detention officer or
contact the ICE Office of the Public Advocate.

What is a Childhood Arrival for Purposes of This Form?

An individual may be considered for deferred action for childhood arrivals if he or she:
1. Was under the age of 31 as of June 15, 2012;

2. Came to the United States before reaching his or her 16th birthday;

3. Has continuously resided in the United States since June 15, 2007, up to the present time;

4. Was present in the United States on June 15, 2012, and at the time of making his or her request for consideration of
deferred action with USCIS;
5. Entered without inspection before June 15, 2012, or his or her lawful immigration status expired as of June 15, 2012;
6. Is currently in school, has graduated or obtained a certificate of completion from high school, has obtained a general
educational development certificate, or is an honorably discharged veteran of the Coast Guard or Armed Forces of the
United States; and
7. Has not been convicted of a felony, significant misdemeanor, three or more other misdemeanors, and does not
otherwise pose a threat to national security or public safety.

Form I-821D Instructions 03/29/13 N

Page 1 of 10

Who May File Form I-821D?
1. Childhood Arrivals Who Have Never Been in Removal Proceedings
If you have never been in removal proceedings, submit this form to request that USCIS consider deferring action in your
case. You must be 15 years of age or older at the time of filing and meet the guidelines described in the Secretary's
memorandum to be considered for deferred action.
2. Childhood Arrivals Whose Removal Proceedings Were Terminated
If you were in removal proceedings which have been terminated by the immigration judge prior to this request, you may
use this form to request that USCIS consider deferring action in your case. You must be 15 years of age or older at the
time of filing and meet the guidelines described in the Secretary's memorandum to be considered for deferred action.
3. Childhood Arrivals In Removal Proceedings, With a Final Removal Order, or With Voluntary Departure

DRAFT
Not for
Production
03/29/2013

If you are in removal proceedings, have a final removal order issued in any other context, have a voluntary departure
order, or if your proceedings have been administratively closed, you may use this form to request that USCIS consider
deferring action in your case, even if you are under the age of 15 at the time of filing. (For this purpose “removal
proceedings” includes exclusion or deportation proceedings initiated before April 1, 1997, an INA section 240 removal
proceeding, expedited removal, reinstatement of removal, an INA section 217 removal after admission under the Visa
Waiver Program, or removal as a criminal alien under INA section 238, or any other kind of removal proceeding under
U.S. immigration law in any other context (for example, at the border or within the United States by an immigration
agent)).

General Instructions

If you are completing this form on a computer, the data you enter will be captured using 2D barcode technology. This
capture will ensure that the data you provide is accurately entered into USCIS systems. As you complete each field, the 2D
barcode field at the bottom of each page will shift as data is captured. Upon receipt of your form, USCIS will use the 2D
barcode to extract the data from the form. Please do not damage the 2D barcode (e.g., puncture, staple, spill on, write on,
etc.) as this could affect the ability of USCIS to timely process your form.
USCIS provides forms free of charge through the USCIS Web site and most are available in PDF format. In order to view,
print, or fill out the USCIS forms, you should use the latest version of Adobe Reader, which can be downloaded for free at
http://get.adobe.com/reader/.
Each request must be properly signed and accompanied by Form I-765 with fees, and Form I-765WS. If you are under 14
years of age, your parent or guardian may sign the request on your behalf. A photocopy of a signed request or typewritten
name in place of a signature is not acceptable. This request is not considered properly filed until accepted by USCIS.
Evidence. You must submit all required initial evidence along with all the supporting documentation with your request at
the time of filing.
Biometric Services Appointment. Individuals requesting consideration of deferred action for childhood arrivals will be
sent a notice scheduling them to appear at an Application Support Center (ASC) for biometrics collection. Failure to
comply with this notice may result in the denial of the deferred action request.
Copies. Unless specifically required that an original document be filed with an application or petition, a legible
photocopy may be submitted. Original documents submitted when not required may remain a part of the record, and will
not be automatically returned to you.
Translations. Any document containing foreign language submitted to USCIS must be accompanied by a full English
language translation which the interpreter has certified as complete and accurate, and by the interpreter's certification that
he or she is competent to translate from the foreign language into English.

Form I-821D Instructions 03/29/13 N

Page 2 of 10

Advance Parole. Requests for advance parole will not be considered unless and until USCIS decides to defer action in
your case. Do not submit Form I-131, Application for Travel Document, with Form I-821D; if you do, the entire submission
will be rejected and returned to you.
How to Fill Out Form I-821D
1. Type or print legibly in black ink.
2. If you need additional space to complete any item, proceed to Part 7., Additional Information, of the form.
3. Answer all questions fully and accurately. If an item is not applicable or the answer is "none," leave the space blank.
4. All dates must be entered as MM/DD/YYYY. You may provide approximate dates if you do not know the exact date.
Do not leave a date response blank.

Initial Evidence

DRAFT
Not for
Production
03/29/2013

1. What Documents Should You Submit With Your Form I-821D?

a. You do not need to submit original documents unless USCIS requests them.

b. Evidence and supporting documents that you file with your Form I-821D should show that you are at least 15 years
of age at the time of filing, if required (See section of these instructions entitled “Who May File Form I-821D?”
for more information) and that you meet all of the following:
(1) Were born after June 15, 1981 (i.e., You were not age 31 or older on June 15, 2012);
(2) Arrived in the United States before the age of 16;

(3) Have continuously resided in the United States since June 15, 2007, up to the present time;
(4) Were present in the United States on June 15, 2012, and at the time of making your request for consideration of
deferred action with USCIS;
(5) Entered without inspection before June 15, 2012, or your lawful immigration status expired as of June 15, 2012;
(6) Are currently in school, graduated or received a certificate of completion from high school, obtained a general
educational development (GED) certificate or other equivalent State-authorized exam in the United States, or
that you are an honorably discharged veteran of the Coast Guard or U.S. Armed Forces.
2. What Documents Do You Need to Provide to Prove Identity?
Submit copies of any of the following:
a. Passport;

b. Birth certificate accompanied by photo identification;

c. Any national identity document from your country of origin bearing your photo and/or fingerprint;
d. Any U.S.-government immigration or other document bearing your name and photograph (e.g., Employment
Authorization Documents (EADs), expired visas, driver's licenses, non-driver cards, etc.);
e. Any school-issued form of identification with photo;
f. Military identification document with photo;
g. State-issued photo ID showing date of birth; or
h. Any other document that you believe is relevant.
NOTE: Expired documents are acceptable.

Form I-821D Instructions 03/29/13 N

Page 3 of 10

3. What Documents May Show That You Came to the United States Before Your 16th Birthday?
Submit copies of any of the following documents:
a. Passport with an admission stamp indicating when you entered the United States;
b. I-94/I-95/I-94W Arrival/Departure Record;
c. Any Immigration and Naturalization Service (INS) or DHS document stating your date of entry (e.g., Form I-862,
Notice to Appear);
d. Travel records, such as transportation tickets showing your dates of travel to the United States;
e. School records (transcripts, report cards, etc.) from the schools that you have attended in the United States, showing
the name(s) of the schools and periods of school attendance;
f. Hospital or medical records concerning treatment or hospitalization, showing the name of the medical facility or
physician and the date(s) of the treatment or hospitalization;

DRAFT
Not for
Production
03/29/2013

g. Official records from a religious entity in the United States confirming your participation in a religious ceremony,
rite, or passage (e.g., baptism, first communion, wedding); or
h. Any other document that you believe is relevant.

4. If before your 16th birthday you left the United States for some period of time before returning on or after your
16th birthday and beginning your current period of continuous residence, what documents may show that you
established residence before your 16th birthday?
Submit copies of any of the following documents:
a. School records (transcripts, report cards, etc.) from the schools that you have attended in the United States, showing
the name(s) of the schools and periods of school attended;
b. Employment records (e.g., pay stubs, W-2 Forms, certification of the filing of Federal income tax returns, State
verification of the filing of state income tax returns, letters from employer(s), or, if you are self employed, letters
from banks and other firms with whom you have done business);
c. Documents evidencing that you were physically present in the United States for multiple years prior to your 16th
birthday; or
d. Any other relevant document.

5. What Documents May Show That You Continuously Resided in the United States Since June 15, 2007, Up to the
Present Date?
Submit copies of any relevant documents such as:

a. Rent receipts, utility bills (gas, electric, phone, etc.), receipts or letters from companies showing the dates during
which you received service;
b. Employment records (e.g., pay stubs, W-2 Forms, certification of the filing of Federal income tax returns, State
verification of the filing of state income tax returns, letters from employer(s), or, if you are self employed, letters
from banks and other firms with whom you have done business);
NOTE: In all of these documents, your name and the name of the employer or other interested organization must
appear on the form or letter, as well as relevant dates. Letters must include: your address(es) at the time of
employment, exact period(s) of employment, period(s) of layoff, and duties with the employer. Letters must also be
signed by the employer and include the employer's contact information.
c. School records (transcripts, report cards, etc.) from the schools that you have attended in the United States, showing
the name(s) of the schools and periods of school attendance;
d. Military records (e.g., Form DD-214, Certificate of Release or Discharge from Active Duty; NGB Form 22,
National Guard Report of Separation and Record of Service; military personnel records; or military health records);

Form I-821D Instructions 03/29/13 N

Page 4 of 10

e. Hospital or medical records concerning treatment or hospitalization, showing the name of the medical facility or
physician and the date(s) of the treatment or hospitalization;
f. Official records from a religious entity in the United States confirming your participation in a religious ceremony,
rite, or passage (e.g., baptism, first communion, wedding);
g. Money order receipts for money sent in or out of the country; passport entries; birth certificates of children born in
the United States; dated bank transactions; correspondence between you and another person or organization; U.S.
Social Security card; automobile license receipts, title, vehicle registration, etc.; deeds, mortgages, rental agreements,
contracts to which you have been a party; tax receipts; insurance policies; receipts; postmarked letters; or
h. Any other relevant document.
6. Do Brief Departures Interrupt Continuous Residence?
A brief, casual, and innocent absence from the United States will not interrupt your continuous residence. If you were
absent from the United States for any period of time, your absence will be considered brief, casual, and innocent, if it
was between June 15, 2007, and August 15, 2012, and:
a. The absence was short and reasonably calculated to accomplish the purpose for the absence;

DRAFT
Not for
Production
03/29/2013

b. The absence was not because of an order of exclusion, deportation, or removal;

c. The absence was not because of an order of voluntary departure, or an administrative grant of voluntary departure
before you were placed in exclusion, deportation, or removal proceedings; and
d. The purpose of the absence and/or your actions while outside of the United States were not contrary to law.
In Part 2., Arrival/Residence Information, list all your absences from the United States since June 15, 2007. Include
information about all your departure and return dates, and the reason for your departure(s).
Documents you can submit that may show your absence was brief, casual, and innocent include, but are not limited to:
a. Plane or other transportation tickets or itinerary showing the travel dates;
b. Passport entries;

c. Hotel receipts showing the dates you were abroad;

d. Evidence of the purpose of the travel (e.g., you attended a wedding or funeral);
e. Copy of advance parole document; and

f. Any other evidence that could support a brief, casual, and innocent absence.

7. What Documents May Demonstrate That You Were Present in the United States on June 15, 2012?
Submit copies of any relevant documents such as:

a. Rent receipts, utility bills (gas, electric, phone, etc.), receipts or letters from companies showing the dates during
which you received service;
b. Employment records (e.g., pay stubs, W-2 Forms, certification of the filing of Federal income tax returns, State
verification of the filing of state income tax returns, letters from employer(s), or, if you are self employed, letters
from banks and other firms with whom you have done business);
NOTE: In all of these documents, your name and the name of the employer or other interested organization must
appear on the form or letter, as well as relevant dates. Letters must include: your address(es) at the time of
employment, exact period(s) of employment, period(s) of layoff, and duties with the employer. Letters must also be
signed by the employer and include the employer's contact information.
c. School records (transcripts, report cards, etc.) from the schools that you have attended in the United States, showing
the name(s) of the schools and periods of school attendance;

Form I-821D Instructions 03/29/13 N

Page 5 of 10

d. Military records (e.g., Form DD-214, Certificate of Release or Discharge from Active Duty; NGB Form 22,
National Guard Report of Separation and Record of Service; military personnel records; or military health records);
e. Hospital or medical records concerning treatment or hospitalization, showing the name of the medical facility or
physician and the date(s) of the treatment or hospitalization;
f. Official records from a religious entity in the United States confirming your participation in a religious ceremony,
rite, or passage (e.g., baptism, first communion, wedding);
g. Money order receipts for money sent in or out of the country; passport entries; birth certificates of children born in
the United States; dated bank transactions; correspondence between you and another person or organization; U.S.
Social Security card; automobile license receipts, title, vehicle registration, etc.; deeds, mortgages, rental agreements,
contracts to which you have been a party; tax receipts; insurance policies; receipts; postmarked letters; or
h. Any other relevant document.

DRAFT
Not for
Production
03/29/2013

8. What Documents May Show You Were in Unlawful Status as of June 15, 2012? (Please submit documents if you
were admitted or paroled, or otherwise obtained a lawful immigration status, on or before June 15, 2012, or you were
or are in removal proceedings.)
Note: For deferred action for childhood arrivals, in unlawful status as of June 15, 2012, means that you never had a
lawful immigration status on or before June 15, 2012, or any lawful immigration status or parole that you obtained
prior to June 15, 2012, had expired before June 15, 2012.
Submit copies of any of the following documents:

a. I-94/I-95/I-94W Arrival/Departure Record showing the date your authorized stay expired;

b. If you have a final order of exclusion, deportation, or removal issued as of June 15, 2012, submit a copy of that
order and related charging documents, if available;
c. An INS or DHS charging document placing you into removal proceedings, if available; or

d. Any other document that you believe is relevant to show that as of June 15, 2012, you were present in the United
States after your lawful status had expired.
9. What Documents May Demonstrate that You Are Either: a) In School in the United States at the Time of Filing;
b) Have Graduated or Received a Certificate of Completion from a U.S. High School, public or private college,
or university or community college; or c) Have obtained a General Educational Development (GED) Certificate
or other equivalent State-authorized exam in the United States? (If applicable)
USCIS recognizes that schools, educational programs, school districts, and state education agencies around the country
issue educational records in a variety of formats. USCIS does not require educational records to be presented in any
particular format.
a. To be considered “currently in school,” you are to be enrolled in one of the following:

(1) A public or private elementary school, junior high or middle school, high school, or secondary school;
(2) An education, literacy, or career training program (including vocational training or an English as a Second
Language (ESL) course) that is designed to lead to placement in post-secondary education, job training, or
employment, and where you are working toward such placement, and that the program:
(a) Is funded in whole or in part by federal, state, local, or municipal funds; or
(b) Is of demonstrated effectiveness;
(3) An education program assisting students either in obtaining a regular high school diploma or its recognized
equivalent under State law (including a certificate of completion, certificate of attendance, or alternate award),
or in passing a GED exam or other equivalent State-authorized exam, and that the program:
(a) Is funded in whole or in part by federal, state, local, or municipal funds; or
(b) Is of demonstrated effectiveness;
Form I-821D Instructions 03/29/13 N

Page 6 of 10

(4) A public or private college or university or a community college.
Evidence of enrollment may include, but is not limited to: school registration cards, acceptance or other letters
demonstrating enrollment or attendance, current transcripts, report cards, progress reports, or other documents
issued by a school district, state education agency, school or program. These documents should show your name;
the name of the school district, educational agency, school, or program issuing the record; the date(s) or time
period(s) of enrollment you are seeking to establish; and your current educational or grade level.
If you have been accepted for enrollment and your classes have not yet begun, you may submit an acceptance letter
with evidence that you have registered for classes or any other relevant evidence showing you have committed to
starting classes on a certain date, including, for example, a copy of your tuition bill, your class schedule, or your
Individualized Educational Program (IEP).
If you are enrolled in an educational, literacy or career training program (including vocational training or an ESL
course), evidence that the program is funded in whole or in part by federal, state, local or municipal funds includes
a letter or other documentation from an authorized representative of the program that includes information such as:
your name and date of enrollment; the duration of the program and expected completion date; the program's source
of public funding, and the program's authorized representative's contact information.

DRAFT
Not for
Production
03/29/2013

If you are enrolled in an education, literacy or career training program that is not publicly funded, evidence that the
program is of demonstrated effectiveness may include information from an authorized school representative relating
to: the duration of the program's existence; the program's track record in placing students in employment, job
training, or post-secondary education; receipt of awards or special achievement or recognition that indicate the
program's overall quality; and/or any other information indicating the program's overall quality.
b. Evidence to show that you meet the educational guideline because you have “graduated from school” or “obtained a
GED certificate” includes, but is not limited to:
(1) A high school diploma from a public or private high school or secondary school;

(2) A recognized equivalent of a high school diploma under state law, including a General Educational Development
(GED) certificate, a certificate of completion, or a certificate of attendance;
(3) A transcript that identifies the date of graduation or program completion;

(4) An enrollment history that shows the date of graduation or program completion;

(5) A degree from a public or private college or university or community college; or
(6) An alternate award from a public or private high school or secondary school.

These documents should show your name; the name of the school district, educational agency, school, or program
issuing the record; the date(s) or time period(s) of enrollment you are seeking to establish; and your date of graduation
or completion.
10. What Documents May Demonstrate That You Are an Honorably Discharged Veteran of the Coast Guard or
Armed Forces of the United States? (If applicable)
Submit copies of the following documents:
a. Form DD-214, Certificate of Release or Discharge from Active Duty;
b. NGB Form 22, National Guard Report of Separation and Record of Service;
c. Military personnel records;
d. Military health records; or
e. Any other relevant document.

Form I-821D Instructions 03/29/13 N

Page 7 of 10

11. What Additional Documents Should You Submit if You Are Currently or Have Been in Removal Proceedings?
Submit a copy of the removal order or any document issued by the immigration judge or the final decision of the Board
of Immigration Appeals (BIA), if available. If you have not been in removal proceedings, this question does not apply
to you.
12. What Other Factors Will USCIS Consider When Making a Determination on Deferred Action?
USCIS will also conduct a background check. USCIS may consider deferring action in your case even if you have
been arrested or detained by any law enforcement officer and charges were filed, or if charges were filed against you
without an arrest. USCIS will evaluate the totality of the circumstances in reaching a decision on deferred action.
In accordance with the Secretary's memorandum, if USCIS determines that you have been convicted of a felony
offense, a significant misdemeanor offense, or three or more other misdemeanors not occurring on the same date and
not arising out of the same act, omission, or scheme of misconduct, or that you otherwise pose a threat to national
security or public safety, USCIS is unlikely to consider you for an exercise of deferred action. See Frequently Asked
Questions (www.uscis.gov/childhoodarrivals).

DRAFT
Not for
Production
03/29/2013

Even if you satisfy the threshold criteria for consideration of deferred action for childhood arrivals, USCIS may deny
your request if it determines, in its unreviewable discretion, that an exercise of prosecutorial discretion is not warranted
in your case.
13. What Else Should You Submit with Form I-821D?

USCIS will not consider deferring action in your case unless your Form I-821D is accompanied by Form I-765 with
fees, and Form I-765WS. The filing fee for the Form I-765 is $380. In addition, you must submit a biometrics fee of
$85 as set forth in the instructions to the Form I-765. Neither the filing fee for the I-765, nor the biometrics fee can be
waived. If you do not include Form I-765 with all applicable fees with Form I-821D, your entire submission will be
rejected.
Note: Individuals requesting consideration of deferred action for childhood arrivals will be sent a notice scheduling
them to appear at an Application Support Center to provide fingerprints, photographs, and signatures (biometrics
collection). Failure to comply with this notice may result in the denial of your deferred action as a childhood arrival
request.

What Is the Filing Fee?

There is no filing fee for Form I-821D. However, you must submit both filing and biometric services fees with Form I-765.
Please read Form I-765 filing instructions for complete information (www.uscis.gov/I-765).

Where to File?

Please visit the USCIS Web site at www.uscis.gov/I-821D or contact the USCIS National Customer Service Center at
1-800-375-5283 for the most current information about where to file this request. For TDD (hearing impaired) call:
1-800-767-1833.

Address Change
If you have changed your address after filing this request, you must inform USCIS within 10 days of moving to your new
address. For information on filing a change of address go to the USCIS Web site at www.uscis.gov/addresschange or
contact the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833.
NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the USCIS Lockbox
facilities do not process change of address requests.

Form I-821D Instructions 03/29/13 N

Page 8 of 10

Processing Information
Initial Processing
After your Form I-821D has been accepted, USCIS will check it for completeness, including submission of the required
initial evidence, and send you a receipt notice. If you do not completely fill out the form and required information, or file
it without the required initial evidence, USCIS may refuse to consider deferring action in your case.
Requests for More Information, Including Biometrics or Interview
USCIS may request more information or evidence, or we may request that you appear at a USCIS office for an interview.
We may also request that you submit the originals of any copy. We will return these originals when they are no longer
required.
If the same documents are required for both Form I-821D and Form I-765 that are filed together, the documents only have
to be submitted once.

DRAFT
Not for
Production
03/29/2013

At the time of any interview or other appearance at a USCIS office, USCIS may require that you provide biometric
information (e.g., photograph, fingerprints) to verify your identity and update your background information.
Decision

USCIS will review your request to determine whether the exercise of prosecutorial discretion is appropriate in your case.
Each case will be considered on an individual, case-by-case basis. Even if you satisfy the threshold criteria for
consideration of deferred action for childhood arrivals, USCIS may determine, in its unreviewable discretion, that
deferred action is not warranted in your case. You will be notified of the decision in writing. There is no appeal or motion
to reopen/reconsider the decision.
Information provided in this request is protected from disclosure to ICE and U.S. Customs and Border Protection (CBP)
for the purpose of immigration enforcement proceedings unless the requestor meets the criteria for the issuance of a Notice
To Appear or a referral to ICE under the criteria set forth in USCIS' Notice to Appear guidance (www.uscis.gov/NTA).
The information may be shared with national security and law enforcement agencies, including ICE and CBP, for
purposes other than removal, including for assistance in the consideration of deferred action for childhood arrivals request
itself, to identify or prevent fraudulent claims, for national security purposes, or for the investigation or prosecution of a
criminal offense. The above information sharing clause covers family members and guardians, in addition to the requestor.
This policy, which may be modified, superseded, or rescinded at any time without notice, is not intended to, does not, and
may not be relied upon to create any right or benefit, substantive or procedural, enforceable at law by any party in any
administrative, civil, or criminal matter.

USCIS Forms and Information

To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain
the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USCIS
forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by telephoning our
USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired) call: 1-800-767-1833.

Penalties
If you knowingly and willfully falsify or conceal a material fact or submit a false document with Form I-821D, we will
deny your Form I-821D and may deny any pending or future immigration benefit request or other request for services. In
addition, individuals may be placed into removal proceedings, face severe penalties provided by law, and be subject to
criminal prosecution.

Form I-821D Instructions 03/29/13 N

Page 9 of 10

USCIS Privacy Act Statement
AUTHORITIES: The information requested on this form, and the associated evidence, is collected under Section 103(a)
of the Immigration and Nationality Act 1952, as amended.
PURPOSE: The primary purpose for providing the requested information on this form is to determine if you warrant
consideration of deferred action.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and
any requested evidence, may delay a final decision and result in the denial of your form.
ROUTINE USES: The information you provide on I-821D may be shared with other federal, state, local, and foreign
government agencies and authorized organizations in accordance with approved routine uses, as described in the
associated published system of records notices [DHS-USCIS-001 - Alien File, Index, and National File Tracking System
and DHS-USCIS-007 Benefit Information System, which can be found at www.dhs.gov/privacy].

DRAFT
Not for
Production
03/29/2013

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. The public reporting burden for this collection of
information is estimated at 2 hours and 45 minutes per response, including the time for reviewing instructions and
completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory
Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140, OMB
No. 1615-0124. Do not mail your completed Form I-821D request to this address.

Is Your Request Complete?

Did you submit Form I-765 along with the filing and biometric services fees ($465) total required for the
application for employment authorization and did you also submit a completed Form I-765WS?
Did you answer each question?

Did you provide an original, handwritten signature and date your request?
Did you submit the necessary documents?

Did you submit evidence to show that you came to the U.S. while under the age of 16?

Did you submit evidence to prove identity, date of initial entry, and continuous residence from June 15, 2007,
(or earlier) up to the present time?
Did you submit evidence that you are currently in school, have a GED certificate, have graduated or received a
certificate of completion from high school, or are an honorably discharged veteran of the Coast Guard or Armed
Forces of the United States?
If you were issued a final order, did you include a copy of that final order (if available)?
If your removal proceedings were terminated by an immigration judge, did you include a copy of the
immigration judge's termination order?
Did you provide evidence showing that you were in unlawful status as of June 15, 2012?

Form I-821D Instructions 03/29/13 N

Page 10 of 10