Form Table of Changes

TABLE OF CHANGES – FORM

FORM I-821, Application for Temporary Protected Status

OMB Number 1615-0043

09/30/2013

Summary of Revisions

• Adding data fields necessary to incorporate Form I-821 into USCIS ELIS and align this form with transformation system requirements;

• Clarifying and updating eligibility-related questions and information throughout Form I-821;

• In support of U.S. Customs and Border Protection’s (CBP’s) automation of Arrival/Departure Records (Forms I-94) at airports and sea ports beginning April 30, 2013, adding passport and travel document data fields  to facilitate verification of admission information collected and maintained by CBP¹;

• Updating applicant, interpreter and preparer certification statements; and

• Including a 2D barcode to expedite data intake and transmission.

LOCATION	CURRENT VERSION	PROPOSED VERSION
Throughout Form	Current Format is full page.	Two column format with all data collections numbered, and some numbers expanded/ revised to accurately capture information, to track information in the USCIS systems, and to make the form more customer friendly. (e.g., a data collection in Part 1, currently numbered “1.” is now numbered “1.a.”) In addition, some sections have sub-section titles added, to clarify the sections in the form.
To be completed by an Attorney/ Representative, if any	Check box if G-28 is attached to represent the applicant Attorney State License Number	[Deleted – Changes made to Part 7]
Page 1, Part 1, Type of Application (check one)	a. This is my first application to register for Temporary Protected Status. 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.	1.a. This is my initial (first-time) application for Temporary Protected Status (TPS). I was not previously granted TPS. 1.b. This is my re-registration application for TPS. I was previously granted TPS. Are you also filing a request for employment authorization? 2.a. 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.b. 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.
Page 1, Part 2. Information About You	…U.S. Mailing Address:  (Street Number and Name) Apt. # C/O: (In Care Of) Town/City State County Zip Code [See below under “Your Current Immigration Status”] [See below under “Your Current Immigration Status”] Other Names Used (including maiden names) …Date of Entry Into the U.S. Place of Entry Into the U.S. Manner of Arrival (Visitor, student, stowaway, without inspection, etc.) Arrival/Departure Record (I-94) Number Date authorized stay expired/or will expire, as shown on Form I-94 or I-95 Your Current Immigration Status: In Status (state nonimmigrant 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? If you answered "Yes" to the above question, provide the following information. Type of proceedings: Exclusion, Removal/Deportation, Rescission, Judicial Proceedings Location of Proceedings Date of Proceedings	[Page 1] …U.S.Mailing Address [new sub-header] 2.a. In Care Of Name (if applicable) 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Is your current mailing address the same as your physical address? If you answered “No” to Item Number 2.g, please provide your physical address below. U.S. Physical Address [new sub-header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code [Page 2] Other Information [new sub-header] 4. Alien Registration Number (A-Number) (if any) 5. USCIS ELIS Account Number (if any) 6. U.S. Social Security Number (if any)… Other Names Used (if any, including maiden names) 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.b. Middle Name Other Dates of Birth Used (if any) 15.a. Date of Birth (mm/dd/yyyy) 15.b. Date of Birth (mm/dd/yyyy) 16. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 17. Race (Select all applicable boxes) White Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native 18. Height Feet Inches 19. Weight Pounds 20. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 21. Hair Color (Select only one box) Bald Black Blonde Brown Gray Red Sandy White Unknown/Other U.S. Entry Information [new sub-header] 22. Date of last entry into the United States? (mm/dd/yyyy) 23. Immigration status when you last entered the United States (e.g., visitor, student, entered without inspection (EWI)) Place of last entry into the United States? 24.a. U.S. Port of Entry (if any) 24.b. City or Town 24.b. State [Page 3] 25.a. Arrival-Departure Record (I-94)? (if any) 25.b. Date authorized period of stay in the United states expired or will expire (as shown on Form I-94 or I-95) 25.c. Passport Number (if any) 25.d. Travel Document Number (if any) 25.e. Country of Issuance for Passport or Travel Document? 25.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) Your Current Immigration Status [sub-header] 26. Current immigration status (e.g., visitor, student, visa overstay, EWI) [See above, Item Numbers 4] [See above, Item Numbers 6] 27. Are you now or were you ever in immigration proceedings? If you answered “Yes” Item Number 27., provide the following information. Type of Proceedings (Select only one box): 28.a. Exclusion 28.b. Removal/Deportation 28.c. Rescission 28.d. I am no longer in immigration proceedings, but I was in Federal court proceedings regarding immigration issues 29. Location where your proceedings were held (or are currently being held) 30. Dates for your proceedings (If your proceeding are ongoing, leave the “To” date blank) (mm/dd/yyyy) From To
Page 2, 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) Apt # Town/City State/Province Country Zip/Postal Code Your Spouse's Birth Date (mm/dd/yyyy) Date and Place of Present Marriage Name of Prior Husbands/Wives Date(s) Marriage(s) Ended (mm/dd/yyyy) 2.  List the names, ages, and current residence of children (if any). [Space to collect information on 5 children] Name (First/Middle/Last) Date of Birth (mm/dd/yyyy Residence	[Page 3-4] Provide the following information about your spouse (if married). 1. USCIS ELIS Account Number (if any)… 2. Alien Registration Number (A-Number) (if any) 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. Zip Code 4.f. Province (if any) 4.g. Postal Code (if any) 4.h. Country (if any) 5. Your Spouse's Date of Birth 6. Date of Present Marriage 7. Place of Present Marriage [Deleted] [Deleted] Provide the following information about each of your children (if any). Child 1 [new subheader] 8.a. USCIS ELIS Account Number (if any) 8.b. Alien Registration Number (A-Number) (if any) 8.c. Family Name (Last Name) 8.d. Given Name (First Name) 8.e. Middle Name 8.f. Date of Birth (mm/dd/yyyy) 8.g. Street Number and Name 8.h. Apt. Ste. Flr. 8.i. City or Town 8.j. State 8.k. Zip Code 8.l. Province (if any) 8.m. Postal Code (if any) 8.n. Country (if any) Child 2 [new subheader] 9.a… 9.n. Child 3 [new subheader] 10.a… 10.n. Child 4 [new subheader] 11.a… 11.n. Child 5 [new subheader] 12.a… 12.n.
Page 2-5, Part 4 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 ... 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? 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? (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? 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 you or have you been a knowing assister, abettor, conspirator, or colluder with others in the illicit trafficking of any controlled substance? (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? (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 in 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? (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 U.S. citizenship, outside the United States from a U.S. citizen granted custody? 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? (ii) killing any person? (iii) intentionally and severely injuring any person? (iv) engaging in any kind of sexual contact or relations with any person who was being forced or threatened? (v) limiting or denying any person's ability to exercise religious beliefs? 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? (ii) served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? 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? 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? 2t. Have you ever received any type of military, paramilitary, or weapons training? 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 Web site at www.uscis.gov or by calling the USCIS toll-free forms line at 1-800-870-3676.	Page 5, Provide the following information: 1.a. I am a national of (or an alien having no nationality who last habitually resided in the country of): 1.b. I entered… 1.c. Have you EVER resided in any country(s) other than the one listed in Item Number 1.a.? 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) 1.e. Dates that you resided in the other country From To 1.f. Your immigration status in the other country (e.g., citizen, permanent resident, refugee, asylee, visitor, temporary resident) 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. 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. Have you EVER been convicted of: 2.a. Any felony committed in the United States? 2.b. Any misdemeanor(s) committed in the United States? 2.c. Any particularly serious crime committed either in or outside the United States? 3.a. Have you EVER ordered… [(See 2.c. above] 3.b. Have you EVER committed serious nonpolitical crimes… 3.c. Have you EVER or are you NOW engaged in… Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of: 4.a. A crime (other than a purely offense)? 4.b. A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? 4.c. A conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? 5.a. 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.b. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? 5.c. Are you or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? 5.d. Are you the spouse or child of an alien who unlawful trafficked in any controlled substance? 5.e. 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.f. 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 unlawful activity? Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following: 6.a. Any activity to violate any law of the United States relating to espionage or sabotage? 6.b. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? 6.c. Any other unlawful activity in the United States? 6.d. 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? 7.a. Have you EVER or are you NOW engaged in… 7.b. Have you EVER or are you NOW engaged in… 7.c. Have you EVER been or are you NOW… 7.d. Have you EVER… 8.a. Have you EVER been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations? 8.b. Have you EVER been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? 9. Have you EVER committed a serious criminal offense… 10.a. Have you EVER, within the past 10 years, or are you NOW engaged in prostitution or procurement of prostitution? 10.b. Have you EVER, within the past 10 years (either directly or indirectly), procured or attempted to procure or to import, prostitutes or persons for the purpose of prostitution? 10.c. Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution? 11. Have you EVER… 12.a. Have you EVER been ordered removed, and been deported from the United States? 12.b. Have you EVER voluntarily departed the United States under an order of removal? 12.c. 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.d. If you answered “Yes” to Item Number 12.c. above, has your prior order of removal been reinstated by DHS? 12.e. Have you EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability? 12.f. 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? 13... Have you EVER… 14.a Do you NOW… 14.b. Do you NOW have or have you EVER… 14.c. Are you NOW or have you EVER … 15. Have you EVER … 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? 17 Are you NOW … 18 Do you NOW … 19. 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? 20. Have you EVER… Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 21a. Acts… 21.b. Killing… 21.c. Intentionally… 21.d. Engaging… 21.e. Limiting… Have you EVER: 22.a. Served … 22.b. Served or worked in … 23… 24 Have you EVER assisted with… 25. Have you EVER … 26. Have you EVER unlawfully voted in a United States Federal, state, or local election? 27. Have you EVER claimed to be a United States citizen (in writing or in any other way)? 28.a. Have you EVER recruited, enlisted, conscripted, or used any person under age 15 to serve in or help an armed force or group? 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? 29.a. Have you EVER committed or conspired to commit human trafficking offenses, as defined in section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States? 29.b. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? 29.c. Are you NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses? 29.d. 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? 29.e. 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? 30.a. Are you NOW or have you EVER engaged in money laundering as described in section 1956 or 1957 of Title 18, United States Code? 30.b. Are you NOW or have you EVER been, a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering? 31. 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? 32. Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous asylum application in the past? 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. 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. 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.
Page 5 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 [Fillable Field], 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 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.	Part 5. Statement, Certification, Signature, and Contact Information of the Applicant [Deleted] NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. [Check Box] 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. [Check Box] 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 [Fillable Field], 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. [Check Box] I have requested the services of and consented to [Fillable Field], who is [Check Box] is not [Check Box] an attorney or accredited representative, preparing this form for me. Applicant Certification: [Sub-header] 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. 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. 3.a. Applicant’s Signature 3.b. Date of Signature (mm/dd/yyyy) 4. Applicant’s Daytime Telephone Number 5. Applicant’s Mobile Telephone Number 6. Applicant’s E-mail Address [Deleted]
Page 6, Part 6. Interpreter’s Statement	[See below, “Print Your Name”] [See below, “Print Your Name”] Language used: [Fillable Field] 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 Print Your Name Date (mm/dd/yyyy)	Part 6. Contact Information, Certification, and Signature of the Interpreter Interpreter’s Full Name [Sub-header] Provide the following information concerning the interpreter: 1.a. Interpreter’s Family Name (Last Name) 1.b. Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address [Sub-header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter’s Contact Information [Sub- header] 4.Interpreter’s Daytime Telephone Number 5.Interpreter’s E-mail Address Interpreter Certification [Sub-header] I certify that: I am fluent in English and [Fillable Field] which is the same language provided in Part 5., Item Number 1.b.; 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. 6.a. Interpreter’s Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 6, Part 7. Preparer’s Statement [	[See below, “Print Your Name”] [See below, “Print Your Name”] [See below, “Firm Name and Address”] [See below, “Firm Name and Address”] [See below, “Daytime Phone Number”] [See below, “Fax Number”] 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? Signature Print Your Name Date (mm/dd/yyyy) Firm Name and Address Daytime Phone Number Fax Number	Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer’s Full Name [Sub-header] Provide the following information concerning the preparer: 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Preparer’s Mailing Address [Sub-header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer’s Contact Information [Sub-header] 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number 6. Preparer’s E-mail Address 7.a. [Check Box] I am not an attorney or accredited representative but have prepared this form on behalf of the applicant and with the applicant’s consent. 7.b. [Check Box] I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends [Check Box] does not extend [Check Box] beyond the preparation of this form. Preparer’s Declaration [Sub-header] 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. 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)
Page 6., Part 8. 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, 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?	[Deleted from the form and placed at the end of the instructions.]

1 CBP will stop issuing paper I-94 Arrival/Departure Records to aliens who enter the United States. I-94 data will be available to such entrants who have access to the Internet to obtain their admission number and electronic I-94 record from the CBP website, www.cbp.gov. In addition to other record checks, the I-94 record information is used by U.S. Citizenship and Immigration Services (USCIS) to verify applicant, petitioner or beneficiary status in the United States at the time an application or petition is filed.

2