Table of Changes - form

TABLE OF CHANGES – FORM

FORM I-821D, Consideration of Deferred Action for Childhood Arrivals

OMB Number: 1615-0124

03/27/2014

Current Section and Page Number	Current Text	Proposed Text
Page 1, START HERE	Type or print in black ink. Read the instructions for information on how to complete the form.	Type or print in black ink. Read Form I-821D Instructions for information on how to complete the form.
Page 1, Part 1. Information About You	I am not in immigration detention and I am requesting consideration of deferred action for childhood arrivals and I have included Form I-765, Application for Employment Authorization, and Form I-765WS, Form I-765 Worksheet. Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name U.S. Mailing Address (Enter the same address on Form I-765) 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 Removal Proceedings Information 3.a. Are you now or have you ever been in removal proceedings (which 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 do you have a removal order issued in any other context (for example, at the border or within the United States by an immigration agent)? If you answered “Yes” to the above question, you must check a box below indicating your current status or outcome of your removal proceedings. 3.b. Status or outcome: 1. Currently in Proceedings (Active) 2. Currently in Proceedings (Administratively Closed) 3. Terminated 4. Subject to a Final Order 3.c. Most Recent Date of Proceedings (mm/dd/yyyy) 3.d. Location of Proceedings	I am not in immigration detention and I have included Form I-765, Application for Employment Authorization, and Form I-765WS, Form I-765 Worksheet; and I am requesting: 1. Consideration of Deferred Action for Childhood Arrivals – Initial Request OR 2. Consideration of of Deferred Action for Childhood Arrivals – Renewal Request AND For this renewal request, my most recent period of Deferred Action for Childhood Arrivals expires on (mm/dd/yyyy [Deleted] Full Legal Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name U.S. Mailing Address (Enter the same address on Form I-765) 4.a. In Care Of Name (if applicable) 4.b. Street Number and Name 4.c. Apt. Ste. Flr. 4.d. City or Town 4.e. State 4.f. ZIP Code Removal Proceedings Information 5. Are you NOW or have you EVER been in removal proceedings, or do you have a removal order issued in any other context (for example, at the border or within the United States by an immigration agent)? NOTE: The term “removal proceedings” includes exclusion or deportation proceedings initiated before April 1, 1997; an Immigration and Nationality Act (INA) section 240 removal proceeding; expedited removal; reinstatement of a final order of exclusion, deportation, or removal; an INA section 217 removal after admission under the Visa Waiver Program; or removal as a criminal alien under INA section 238. If you answered “Yes” to Item Number 5., you must select a box below indicating your current status or outcome of your removal proceedings. Status or outcome: 5.a. Currently in Proceedings (Active) 5.b. Currently in Proceedings (Administratively Closed) 5.c. Terminated 5.d. Subject to a Final Order 5.e. Other. Explain in Part 8. Additional Information. 5.f. Most Recent Date of Proceedings (mm/dd/yyyy) 5.g. Location of Proceedings
Page 2, Part 1. Information About You	4. Alien Registration Number (A-Number)(if any) 5. U.S. Social Security Number (if any) 6. Date of Birth 7. Gender Male/Female 8.a. City/Town/Village of Birth 8.b. Country of Birth 9. Current Country of Residence 10. Country of Citizenship/Nationality 11. Marital Status Other Names Used (including maiden name) If you require additional space, use Part 7., Additional Information. 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name	[Page 2] Other Information 6. Alien Registration Number (A-Number) (if any) 7. U.S. Social Security Number (if any) 8. Date of Birth 9. Gender Male/Female 10.a. City/Town/Village of Birth 10.b. Country of Birth 11. Current Country of Residence 12. Country of Citizenship or Nationality 13. Marital Status Other Names Used (Including maiden name) If you require additional space, use Part 8. Additional Information. 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name Processing Information 15. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 16. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 17. Height Feet Inches 18. Weight Pounds 19. Eye Color (Select only one box.) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 20. Hair Color (Select only one box.) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Page 3, Part 2. Arrival/Residence Information	Part 2. Arival/Residene Information 1.a. I initially arrived and established residence in the U.S. prior to the age of 16. 1.b. I have been continuously residing in the U.S. since at least June 15, 2007 up to the present time. Note: If you departed the United States for some period of time before your 16th birthday and returned to the United States on or after your 16th birthday to begin your current period of continuous residence, submit evidence that you established residence in the United States prior to age 16 as set forth in the instructions to this form. List your current address and, to the best of your knowledge, the addresses where you resided since your initial entry into the United States. If you require additional space, use Part 7. Additional Information Present Address… 2.f. Zip Code… 3.f. Zip Code… 4.f. Zip Code… 5.f. Zip Code List all of your absences from the United States since June 15, 2007. If you require additional space, use Part 7., Additional Information. 6.a. Departure Date 1 (mm/dd/yyyy) 6.b. Return Date 1 (mm/dd/yyyy) 6.c. Reason for Departure 7.a. Departure Date 2 (mm/dd/yyyy) 7.b. Return Date 2 (mm/dd/yyyy) 7.c. Reason for Departure	Part 2. Residence and Travel Information (For Initial and Renewal Requests) [Deleted] 1. I have been continuously residing in the U.S. since at least June 15, 2007, up to the present time. NOTE:  If you departed the United States for some period of time before your 16th birthday and returned to the United States on or after your 16th birthday to begin your current period of continuous residence, and if this is an initial request, submit evidence that you established residence in the United States prior to16 years of age as set forth in the instructions to this form. For Initial Requests: List your current address and, to the best of your knowledge, the addresses where you resided since the date of your initial entry into the United States to present. For Renewal Requests: List only the addresses where you resided since you submitted your last Form I-821D that was approved. If you require additional space, use Part 8. Additional Information [Page 3] Present Address 2.f. ZIP Code… 3.f. ZIP Code… 4.f. ZIP Code… 5.f. ZIP Code Travel Information For Initial Requests: List all of your absences from the United States since June 15, 2007. For Renewal Requests: List only your absences from the United States since you submitted your last Form I-821D that was approved. If you require additional space, use Part 8. Additional Information. Departure 1 6.a. Departure Date (mm/dd/yyyy) 6.b. Return Date (mm/dd/yyyy) 6.c. Reason for Departure Departure 2 7.a. Departure Date (mm/dd/yyyy) 7.b. Return Date (mm/dd/yyyy) 7.c. Reason for Departure 8. Have you left the United States without advance parole since August 15, 2012? 9.a. What country issued your last passport? 9.b. Passport Number 9.c. Passport Expiration Date (mm/dd/yyyy) 10. Border Crossing Card Number (if any)
Page 2, Part 1. Information About You [continued]	U.S. Entry and Status Information 13. Date of Initial Entry into the United States, on or about (mm/dd/yyyy) 14. Place of Entry into the United States 15. Status on June 15, 2012 (e.g., No Lawful Status, Status Expired, Parole Expired) 16.a. Do you have an Arrival/Departure Record (I-94) 16.b. If you answered “Yes”, provide your I-94 number (if applicable) 17. Date authorized stay expired, as shown on Form I-94, I-95, or I-94W (if applicable) Education Information 18. Education Status (e.g. High School Graduate, Recipient of GED, or Currently in School) 19. Name… 20. Date of Graduation (e.g., Receipt of a Certificate of Completion, GED Certificate, or other equivalent State-authorized exam) or, if Currently in School, Date of Last Attendance (mm/dd/yyyy) Military Service Information 21.a. Were you a member of the U.S. Armed Forces or Coast Guard? If you answered “Yes” to the above question, you must provide responses to Item Numbers 21.b. through 21.e. 21.b. Military Branch 21.c. Service Start Date (mm/dd/yyyy) 21.d. Discharge Date (mm/dd/yyyy) 21.e. Type of Discharge	Part 3. For Initial Requests Only 1.a. I initially arrived and established residence in the U.S. prior to 16 years of age. 2. Date of Initial Entry into the United States, on or about (mm/dd/yyyy) 3. Place of Initial Entry into the United States [Page 4] 4. Immigration Status on June 15, 2012 (e.g., No Lawful Status, Status Expired, Parole Expired) 5.a. Were you EVER issued an Arrival/Departure Record (I-94) 5.b. If you answered “Yes”, provide your I-94 number (if available) 5.c. If you answered "Yes" to Item Number 5.a., provide the date your authorized stay expired, as shown on Form I-94, I-94W, or I-95 (if available). Education Information 6. Indicate how you meet the education guideline (e.g., Graduated from high school, Received a general educational development (GED) certificate or equivalent state-authorized exam, Currently in school) 7. Name… 8. Date of Graduation (e.g., Receipt of a Certificate of Completion, GED certificate, other equivalent state authorized exam) or, if currently in school, Date of Last Attendance (mm/dd/yyyy) Military Service Information 9. Were you a member of the U.S. Armed Forces or U.S. Coast Guard? If you answered “Yes” to Item Number 9., you must provide responses to Item Numbers 9.a. - 9.d. 9.a. Military Branch 9.b. Service Start Date (mm/dd/yyyy) 9.c. Discharge Date (mm/dd/yyyy) 9.d. Type of Discharge
Page 4, Part 3. Criminal, National Security and Public Safety Information	If any of the following questions apply to you, use Part 7., Additional Information, to describe the circumstances and include a full explanation. 1. Have you ever been arrested for, charged with, or convicted of a felony or misdemeanor in the United States? Do not include minor traffic violations unless they were alcohol- or drug-related. Do include incidents handled in juvenile court… 2. Have you ever been… 3. Have you ever engaged … 4. Are you now or have ever been a member of a gang? Have you ever engaged in, ordered, incited, assisted or otherwise participated in any of the following…	[Page 4] Part 4. Criminal, National Security, and Public Safety Information (For Initial and Renewal Requests) If any of the following questions apply to you, use Part 8. Additional Information, to describe the circumstances and include a full explanation. 1. Have you EVER been arrested for, charged with, or convicted of a felony or misdemeanor, including incidents handled in juvenile court, in the United States? Do not include minor traffic violations unless they were alcohol- or drug-related… 2. Have you EVER been… 3. Have you EVER engaged … 4. Are you NOW or have EVER been a member of a gang? 5. Have you EVER engaged in, ordered, incited, assisted, or otherwise participated in any of the following… 6. Have you EVER recruited, enlisted, conscripted, or used any person to serve in or help an armed force or group while such person was under age 15? 7. 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 4, Part 4. Signature of Requestor	Requestor's Statement (check one) 1.a… 1.b. 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. Requestor'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 USCIS needs to reach a determination on deferred action. 2.a. Signature of Requestor 2.b. Date of Signature (mm/dd/yyyy) 3. Daytime Phone Number NOTE: Deferred action is unlikely to be considered for anyone who fails to completely fill out this form or to submit required documents listed in the instructions. Deferred action does not confer lawful status upon an individual. Furthermore, a decision on deferred action is wholly within the discretion of DHS. 4. Did someone help you prepare this form or a portion of it? (You must answer Yes or No.) If yes, complete Part 5., Signature of Person Preparing This Request, If Other Than the Requestor.	[Page 5] Part 5. Statement, Certification, Signature, and Contact Information of the Requestor (For Initial and Renewal Requests) NOTE: Select the box for either Item Number 1.a. or 1.b. 1.a… 1.b. The interpreter named in Part 6. 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. Requestor’s Certification I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct and that copies of documents submitted are exact photocopies of unaltered original documents. I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. I also understand that knowingly and willfully providing materially false information on this form is a federal felony punishable by a fine, imprisonment up to 5 years, or both, under 18 U.S.C. section 1001. Furthermore, I authorize the release of any information from my records that USCIS may need to reach a determination on my derferred action request. 2.a. Requestor's Signature 2.b. Date of Signature (mm/dd/yyyy) Requestor's Contact Information 3 Requestor's Daytime Telephone Number 4. Requestor's Mobile Telephone Number 5. Requestor's Email Address [Deleted]
Page 5, Part 6. Signature of Interpreter	Interpreter's Information 3.a. Interpreter's Family Name (Last Name) 3.b. Interpreter's Given Name (First Name) 1. Language Used I certify that I am fluent in English and the language above. 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 requestor in the above mentioned language, and that the requestor has informed me that he or she has understood each and every instruction and question of the form, as well as the answer to each question. 2.a. Signature of Interpreter 2.b. Date of Signature (mm/dd/yyyy)	[Page 5] Part 6. Contact Information, Certification, and Signature of the Interpreter (For Initial and Renewal Requests) Interpreter's Full Name 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 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 4. Interpreter's Daytime Telephone Number 5. Interpreter's Email Address [Page 6] Interpreter’s Certification 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 requestor 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 requestor 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 5, Part 5. Signature and Contact Information of Person Preparing This Form, If Other Than the Requestor	Preparer's Full Name… Preparer's Mailing Address… Preparer's Contact Information 4. Daytime Phone Number 5. Email Address Preparer's Declaration To be completed by all preparers, including attorneys and authorized representatives. I declare that I prepared this Form I-821D at the requestor's behest, and it is based on all the information of which I have knowledge. 6.a. Signature of Preparer 6.b. Date of Signature (mm/dd/yyyy)	[Page 6] Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, If Other than the Requestor (For Initial and Renewal Requests) Preparer's Full Name… Preparer's Mailing Address… 3.f. Province 3.g. Postal Code 3.h. Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's Email Address Preparer's Declaration I declare that I prepared this Form I-821D at the requestor's behest, and it is based on all the information of which I have knowledge. 7a. Preparer's Signature 7.b. Date of Signature (mm/dd/yyyy) NOTE: If you need extra space to complete any item within this request, see the next page for Part 8. Additional Information.
Page 6, Part 7. Additional Information	Part 7. Additional Information If you require more space to provide any additional information within this request, please use the space below. If you require more space than what is provided to complete this request, you may use a separate sheet(s) of paper. You must include your full name on each sheet of paper along with the page number, Part Number, and Item Number related to your explanation. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2.a. Page Number 2.b. Part Number 2.c. Item Number 2.d. [Narrative space] 3.a…3.d… 4.a… 4.d…	[Page 7] Part 8. Additional Information (For Initial and Renewal Requests) If you need extra space to complete any item within this request, use the space below. You may also make copies of this page to complete and file with this request. Include your name and A-Number (if any) at the top of each sheet of paper; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Narrative space] 4.a…4.d… 5.a… 5.d… 6.a. Signature 6.b. Date of Signature (mm/dd/yyyy)

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