Form I-821 Table of Changes

TABLE OF CHANGES – Form

Form I-821, Application for Temporary Protected Status

OMB Number: 1615-0043

02/23/2017

Reason for Revision: IC collection, and addition of online filing language.

Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or accredited representative (if any).		[Page 1] To be completed by an attorney or accredited representative (if any).  [ ] Select this box if Form G-28 or G-28I is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 1, Part 1. Type of Application (check one)	[page 1] Part 1. Type of Application (check one) [new] 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] START HERE - Type or print in black ink. Part 1. Type of Application (select one) NOTE: Select the box for Item Number 1.a., 1.b., or 1.c. If applicable, select the box for Item Number 3.a. or 3.b. 1.a. This is my initial (first time) application for Temporary Protected Status (TPS). I do not currently have TPS. 1.b. This is my re-registration application for TPS. I currently have TPS, and am applying to re-register. NOTE: If you have previously applied or have a pending application for TPS, but do not currently have TPS, select Item Number 1.a. and describe each time that you previously applied, including the receipt number (if available) and the outcome (if any) of each application. If you currently have a pending TPS application, please also describe when you filed it and the application receipt number (if available) in Part 11. Additional Information. If you do not recall or have incomplete information on your prior TPS applications, please provide the information you can, even if incomplete. 2. If you selected Item Number 1.b., please indicate who granted you TPS. [] USCIS [] Immigration Judge/Board of Immigration Appeals Are you also filing a request for employment authorization? 3.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. 3.b. No, I am not currently requesting an EAD.
Pages 1-3, Part 2. Information About You	[page 1] Part 2. Information About You 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name [Page 2] Other Names Used (if any, including maiden name) 14.a. Family Name (Last Name) 14.b. Given Name (First Name) 14.c. Middle Name [Page 1] U.S. Mailing Address 2.a. In Care Of Name 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? Yes/No If you answered "No" to Item Number 2.g., please provide your physical address below. U.S. Physical Address 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 4. Alien Registration Number (A-Number) (if any) 5. USCIS ELIS Account Number (if any) 6. U.S. Social Security Number (if any) 7. Date of Birth (mm/dd/yyyy) Other Dates of Birth Used (if any) 8. Gender 9. City/Town/Village of Birth 10. Country of Birth 11. Country of Residence 12. Country of Citizenship/Nationality (if any) 13. Marital Status 15.a. Date of Birth (mm/dd/yyyy) 15.b. Date of Birth (mm/dd/yyyy) U.S. Entry Information 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.c. State [page 3] 25.a. Arrival-Departure Record (Form 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) (mm/dd/yyyy) 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 26. Current immigration status (e.g., visitor, student, visa overstay, EWI) 27. Are you now or were you ever in immigration proceedings? If you answered "Yes" to 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 proceedings are ongoing, leave the "To" date blank) From: (mm/dd/yyyy) To: (mm/dd/yyyy)	[Page 1] Part 2. Information About You Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name [Page 2] Other Names Used Provide all other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name ­­­­­­­­­_____________________________________ 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name U.S. Mailing Address 4.a. In Care Of Name 4.b. Street Number and Name 4.c. Apt. Ste. Flr. 4.d. City or Town 4.e. State 4.f. ZIP Code 5. Is your current mailing address the same as your physical address (where you live)? Yes/No If you answered "No" to Item Number 5., please provide your physical address below. U.S. Physical Address 6.a. Street Number and Name 6.b. Apt. Ste. Flr. [Fillable field] 6.c. City or Town 6.d. State 6.e. ZIP Code Other Information 7. Alien Registration Number (A-Number) (if any) 8. USCIS Online Account Number (if any) 9. U.S. Social Security Number (if any) 10. Date of Birth (mm/dd/yyyy) Other Dates of Birth Used (if any) Provide all other dates of birth you have ever used. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 11.a. Other Date of Birth (mm/dd/yyyy) 11.b. Other Date of Birth (mm/dd/yyyy) 12. Gender Male/Female 13. City/Town/Village of Birth 14. Country of Birth 15. Countries of Residence (Before entering the U.S.) 16. Country or Countries of Citizenship or Nationality (if any) (List all countries that apply) Your Marital Information 17. Current Marital Status (Select only one box) Single, Never Married Married Divorced Widowed Separated Marriage Annulled Other [delete] [delete] [Page 3] 18. Date of Current Marriage (if currently married) (mm/dd/yyyy) U.S. Entry Information 19. Date of Last Entry into the United States (mm/dd/yyyy) 20. Immigration Status (or Lack of Status) When You Last Entered the United States (for example, visitor, student, no status) Place of Last Entry into the United States 21. U.S. Port of Entry (if any) 22.a. City or Town 22.b. State 23. Form I-94 Arrival-Departure Record Number (if any) 24. Date Your Authorized Period of Stay in the United States Expired or Will Expire (as shown on Form I-94 or Crewman’s Landing Permit (Form I-95)) (mm/dd/yyyy or duration of status (D/S) 25. Passport Number (most recent passport) (if any) (If you have other expired or valid passports, please list all of them and provide all information requested below about each passport.) 26. Travel Document Number (if any) 27. Additional Passport or Travel Document Number 28. Additional Passport or Travel Document Number 29. Country of Issuance for most recent Passport or Travel Document 30. Expiration Date for most recent Passport or Travel Document (mm/dd/yyyy) Your Current Immigration Status 31. Current Immigration Status or Lack of Status 32. Are you now or were you EVER in immigration proceedings? Yes/No If you answered "Yes" to Item Number 32., provide the following information. Type of Proceedings (Select all boxes that apply): 33.a. Immigration Court (before an Immigration Judge) 33.b. Board of Immigration Appeals (BIA) [delete] 33.c. I am no longer in Department of Justice (DOJ) or Department of Homeland Security (DHS) immigration proceedings, but I am or was in Federal court proceedings regarding immigration issues. 34. Locations Where Your DOJ and/or DHS Proceedings were Held (or are currently being held) (if applicable) 35. Locations Where Your Federal Court Proceedings Regarding Immigration Issues were Held (or are currently being held) (if applicable) Dates for Your Proceedings NOTE:  If your proceedings are ongoing, leave the “To” date blank.  If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period. 36.a.      From (mm/dd/yyyy) 36.b.      To (mm/dd/yyyy) 36.c. [] Present
Page 2, Information About You	[Page 2] 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 American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 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 (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other	[Page 3] Part 3. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander [Page 4] 3. Height Feet Inches 4. Weight Pounds 5. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Pages 3-4, Part 3. Information About Your Spouse and Children (if any)	[page 3] Part 3. Information About Your Spouse and Children (if any) 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 Mailing Address of Spouse 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) [page 4] Other Information About Spouse 5. Your Spouse's Date of Birth (mm/dd/yyyy) 6. Date of Present Marriage (mm/dd/yyyy) 7. Place of Present Marriage	[Page 4] Part 4. Information About Your Current Spouse (if any) Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses and all of your children, please use the space provided in Part 11. Additional Information. Provide the following information about your current spouse (if married). 1. USCIS Online Account Number (if any, and if known) 2. A-Number (if any, and if known) 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Mailing Address of Spouse 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 4.g. Postal Code 4.h. Country Other Information About Your Current Spouse 5. Your Spouse's Date of Birth (mm/dd/yyyy) 6. Date of Marriage to Your Current Spouse (mm/dd/yyyy) 7. Place of Marriage to Your Current Spouse 8.a. City or Town 8.b. State 8.c. Province (if any) 8.d. Country 9. If you know, has your current spouse EVER had TPS? Yes No If yes, what dates did he or she have TPS? 10.a. From (mm/dd/yyyy) 10.b. To (mm/dd/yyyy) 10.c. Present 10.d. I do not know the dates 11. Is your spouse’s TPS still valid? (if known) Yes/No/I do not know
New		[Page 5] Part 5. Information About Your Former Spouses (if any) Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses or all of your children, please use the space provided in Part 11. Additional Information. Names of All Your Former Spouses (if any) First Marriage 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Nationalities of Former Spouse 3. A-Number of Former Spouse (if any and if known) 4. Date of Birth of Former Spouse (mm/dd/yyyy) 5. Date of Death if Former Spouse Deceased (mm/dd/yyyy) Dates of Marriage to Former Spouse 6.a. From (mm/dd/yyyy) 6.b. To (mm/dd/yyyy) 7. How Marriage Ended (for example, divorce, widowed, annulled) 8. Did or does this former spouse have TPS (if known)? Yes/No/I do not know If yes, what dates did he or she have TPS (if known)? 9.a.      From (mm/dd/yyyy) 9.b.      To (mm/dd/yyyy) 9.c.     Present 9.d. I do not know the dates 10. Is this former spouse currently applying for or re-registering for TPS (if known)? Yes/No/I do not know Second Marriage 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. Nationalities of Former Spouse 13. A-Number of Former Spouse (if any and if known) 14. Date of Birth of Former Spouse (mm/dd/yyyy) 15. Date of Death if Former Spouse Deceased (mm/dd/yyyy): Dates of Marriage to Former Spouse 16.a. From (mm/dd/yyyy) 16.b. To (mm/dd/yyyy) 17. How Marriage Ended (for example, divorce, widowed, annulled) 18. Did or does this former spouse have TPS (if known)? Yes/No/I do not know If yes, what dates did he or she have TPS (if known)? 19.a.      From (mm/dd/yyyy) 19.b.      To (mm/dd/yyyy) 19.c.     Present 19.d. I do not know the dates 20. Is this former spouse currently applying for or re-registering for TPS (if known)? Yes/No/I do not know
Pages 4-5, Part 3. Information About Your Spouse and Children (if any)	Children (if any) Provide the following information about each of your children (if any). Child 1 8.c. Family Name (Last Name) 8.d. Given Name (First Name) 8.e. Middle Name 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 9.c. Family Name (Last Name) 9.d. Given Name (First Name) 9.e. Middle Name 9.a. USCIS ELIS Account Number (if any) 9.b. Alien Registration Number (A-Number) (if any) 9.f. Date of Birth (mm/dd/yyyy) 9.g. Street Number and Name 9.h. Apt. Ste. Flr. 9.i. City or Town 9.j. State 9.k. ZIP Code 9.l. Province (if any) 9.m. Postal Code (if any) 9.n. Country (if any) Child 3 10.a. USCIS ELIS Account Number (if any) 10.b. Alien Registration Number (A-Number) (if any) 10.c. Family Name (Last Name) 10.d. Given Name (First Name) 10.e. Middle Name 10.f. Date of Birth (mm/dd/yyyy) [page 5] 10.g. Street Number and Name 10.h. Apt. Ste. Flr. 10.i. City or Town 10.j. State 10.k. ZIP Code 10.l. Province (if any) 10.m. Postal Code (if any) 10.n. Country (if any) Child 4 11.a. USCIS ELIS Account Number (if any) 11.b. Alien Registration Number (A-Number) (if any) 11.c. Family Name (Last Name) 11.d. Given Name (First Name) 11.e. Middle Name 11.f. Date of Birth (mm/dd/yyyy) 11.g. Street Number and Name 11.h. Apt. Ste. Flr. 11.i. City or Town 11.j. State 11.k. ZIP Code 11.l. Province (if any) 11.m. Postal Code (if any) 11.n. Country (if any) Child 5 12.a. USCIS ELIS Account Number (if any) 12.b. Alien Registration Number (A-Number) (if any) 12.c. Family Name(Last Name) 12.d. Given Name(First Name) 12.e. Middle Name 12.f. Date of Birth (mm/dd/yyyy) 12.g. Street Number and Name 12.h. Apt. Ste. Flr. 12.i. City or Town 12.j. State 12.k. ZIP Code 12.l. Province (if any) 12.m. Postal Code (if any) 12.n. Country (if any)	[Page 6] Part 6. Information About Your Children (if any) Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses or all of your children, please use the space provided in Part 11. Additional Information. Provide the following information about each of your children (if any). If you need extra space to complete this section, use the space provided in Part 11. Additional Information. Child 1 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. USCIS Online Account Number (if any and if known) 3. Alien Registration Number (A-Number) (if any and if known) [delete] 4. Date of Birth (mm/dd/yyyy) Mailing Address 5.a. Street Number and Name 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. State 5.e. ZIP Code 5.f. Province 5.g. Postal Code 5.h. Country If this child has or had TPS, please provide the dates of his or her TPS (if known). 6.a. From: (mm/dd/yyyy) 6.b. To: (mm/dd/yyyy) 7. If you know, is this child currently applying for or re-registering for TPS (if known)? ______________________________________ Child 2 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Middle Name 9. USCIS Online Account Number (if any and if known) 10. Alien Registration Number (A-Number) (if any and if known) 11. Date of Birth (mm/dd/yyyy) Mailing Address 12.a. Street Number and Name 12.b. Apt. Ste. Flr. 12.c. City or Town 12.d. State 12.e. ZIP Code 12.f. Province 12.g. Postal Code 12.h. Country If this child has or had TPS, please provide the dates of his or her TPS (if known). 13.a. From (mm/dd/yyyy) 13.b. To (mm/dd/yyyy) 14. If you know, is this child currently applying for or re-registering for TPS (if known)? [delete]
Pages 6-9, Part 4. Eligibility Standards	Part 4. Eligibility Standards 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 the United States on the following date, and have resided in the United States since that time. (mm/dd/yyyy) 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: (mm/dd/yyyy) To: (mm/dd/yyyy) 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, 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? 3.b. Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States? 3.c. Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States? 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 political 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? [page 7] 5.b. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? 5.c. Are you NOW 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 unlawfully 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 illicit 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 terrorist activities? 7.b. Have you EVER or are you NOW engaged in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States? 7.c. Have you EVER been or are you NOW a member of the Communist or other totalitarian party, except when membership was involuntary? 7.d. Have you EVER participated in Nazi persecution or genocide? 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 in the United States and asserted immunity from prosecution? 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 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 been or do you intend to be involved in any other commercial vice? 12.a. Have you EVER been ordered removed, and been deported from the United States? [page 8] 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 assisted any other person to enter the United States in violation of the law? 14.a. Do you NOW have a communicable disease of public health significance? 14.b. Do you NOW have or have you EVER 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? 14.c. Are you NOW or have you EVER been a drug abuser or drug addict? 15. Have you EVER entered the United States as a stowaway? 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 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)? 18. Do you NOW practice polygamy? 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 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? Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 21.a. Acts involving torture or genocide? 21.b. Killing any person? 21.c. Intentionally and severely injuring any person? 21.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? 21.e. Limiting or denying any person's ability to exercise religious beliefs? Have you EVER: 22.a. 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? 22.b. Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? [page 9] 23. 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? 24. Have you EVER assisted with 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? 25. Have you EVER received any type of military, paramilitary, or weapons training? 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 the 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 6] Part 7. Eligibility Standards Basis for Eligibility Provide the following information: 1.a. I am a national of (or a person having no nationality who last habitually resided in the country of): [Page 7] 1.b. I entered the United States on the following date, and have resided in the United States since that time. (mm/dd/yyyy) 1.c. Have you EVER traveled to and entered another country, other than the one listed in Item Number 1.a. before you last entered the United States? If you answered "Yes" to Item Number 1.c., provide the information requested in Item Numbers 2. – 5. for EACH country you traveled to and entered prior to entering the United States. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 2. Name of All the Other Countries to Which You Traveled and Entered Prior to Entering the United States Dates That You Were in the Other Country or Countries 3.a. From (mm/dd/yyyy) 3.b. To (mm/dd/yyyy) 4. Your Immigration Status, if Any, in the Other Country (for example, citizen, legal permanent resident, refugee, asylee, visitor, student, temporary resident, or no status) 5. Have you EVER been offered any immigration status by another country that you did not accept? 6. If you answered “Yes” to Item Number 5., please describe the country or countries, the nature of the immigration status you were offered, and the dates when it was offered. 7. If you answered “Yes” to Item Number 5., please describe why you chose not to accept the immigration status offered to you by the other country or countries. Your Immigration and Criminal History To be eligible for TPS, you must be admissible as an immigrant to the United States, with certain exceptions. The questions below and your responses to these questions will help USCIS determine if you are eligible for TPS. See the Who Is Eligible for TPS section of the Instructions for additional information on admissibility and available waivers. If any of the questions apply to you, please provide information about the events, including the places and dates of occurrence. Provide a full explanation of the circumstances related to the specific event. If you need additional space to respond to a question, use the space provided in Part 11. Additional Information. Criminal Offenses If you were EVER arrested or detained for an offense, you must provide information about the event regardless of the country where the event occurred. If you were arrested, charged, or convicted for an offense, you must provide certified court dispositions showing the court proceedings’ outcome wherever possible. You also must provide copies of arrest reports, statements of charges, indictment information, or any other charging document issued against you. If you were not charged with any crime or offense, provide a statement or other documentation from the arresting authority or prosecutor’s office to show that you were not charged with any crime or offense. NOTE: If you are not able to provide the documentation requested above, provide a signed statement as to why you cannot provide such documentation. USCIS usually needs supporting documentation, however, we do recognize that country conditions in certain TPS-designated countries may not allow an applicant to obtain the documents. Each statement will be carefully reviewed by USCIS, and we may need to ask you for additional information. Please carefully read Item 6. in the General Requirements section of the Instructions for additional information that you must provide if official documents regarding your criminal history are not available to you. Human Rights Violations If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred. Have you EVER been convicted of: 8.a. Any felony committed in the United States? 8.b. Any misdemeanor committed in the United States? [Page 8] 8.c. Any particularly serious crime committed either in or outside the United States? 9.a. Have you EVER 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? 9.b. Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States? 9.c. Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States? Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of: 10.a. A crime (other than a purely political offense)? 10.b. A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? 10.c. A conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? 11. 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 five years or more? 12.a. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? 12.b. Are you NOW or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? 12.c. Are you the spouse or child of an alien who unlawfully trafficked in any controlled substance? 12.d. 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? 12.e. Within the previous five 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 illicit activity? Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following: 13.a. Any activity to violate any law of the United States relating to espionage or sabotage? 13.b. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? 13.c. Any other unlawful activity in the United States? 13.d. Any activity in which a purpose is to oppose, control, or overthrow 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? 14.a. Have you EVER or are you NOW engaged in terrorist activities? 14.b. Have you EVER or are you NOW engaged in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States? 14.c. Have you EVER been or are you NOW a member of the Communist or other totalitarian party, except when membership was involuntary? 14.d. Have you EVER participated in Nazi persecution or genocide? Have you EVER, whether in the United States or any other country been: 15.a. Arrested, for breaking or violating any law or ordinance, excluding minor traffic violations? Y/N 15.b. Cited, charged, or indicted, for breaking or violating any law or ordinance, excluding minor traffic violations? Y/N 15.c. Been convicted, fined, imprisoned, placed on probation, received a suspended sentence or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations? Y/N [Page 9] 16. Have you EVER been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? 17. Have you EVER committed a serious criminal offense in the United States and asserted immunity from prosecution? 18.a. Have you EVER, within the past 10 years, or are you NOW engaged in prostitution or procurement of prostitution? 18.b. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? 18.c. Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution? 19. Have you EVER been or do you intend to be involved in any other commercial vice? 20.a. Have you EVER been ordered removed, and been deported from the United States? 20.b. Have you EVER voluntarily departed the United States under an order of removal? 20.c. If you answered "Yes" to either Item Number 20.a. or 20.b. above, have you re-entered the United States unlawfully at any time after you were deported or you voluntarily departed? 20.d. If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal? Yes/No/I do not know 20.e. Have you EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability? 21. 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? 22. Have you EVER assisted any other person to enter the United States in violation of the law? 23.a. Do you NOW have a communicable disease of public health significance? 23.b. Do you NOW have or have you EVER 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? 23.c. Are you NOW or have you EVER been a drug abuser or drug addict? 24. Have you EVER entered the United States as a stowaway? 25. 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? 26. Are you NOW 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)? 27. Do you NOW practice polygamy? 28. Are you NOW the guardian of, and are you accompanying, another individual 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? 29. Have you EVER 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? Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 30.a. Acts involving torture or genocide? 30.b. Killing any person? 30.c. Intentionally and severely injuring any person? 30.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? 30.e. Limiting or denying any person's ability to exercise religious beliefs? [Page 10] Have you EVER: 31.a. 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? 31.b. Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? 32. 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? 33. Have you EVER assisted with 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? 34. Have you EVER received any type of military, paramilitary, or weapons training? 35. Have you EVER unlawfully voted in a United States Federal, state, or local election? 36. Have you EVER claimed to be a U. S. citizen (in writing or in any other way)? 37.a. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? 37.b. Have you EVER used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat? 38.a. Have you EVER committed or conspired to commit human trafficking offenses, as defined in the section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States? 38.b. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? 38.c. Are you NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses? 38.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? 38.e. Within the previous five years, have you EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking? 39.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? 39.b. Are you NOW or have you EVER been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering? 40. 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? 41. Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous asylum application in the past? [delete]
Page 10, Part 5. Statement, Certification, Signature, and Contact Information of the Applicant	Part 5. Statement, Certification, Signature, and Contact Information of the Applicant NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. 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. 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. I have requested the services of and consented to [fillable field], who is/is not an attorney or accredited representative, preparing this form for me. 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address Applicant 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 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)	[Page 10] Part 8. Applicant’s Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-821 Instructions before completing this part. You must file Form I-821 while in the United States. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. The interpreter named in Part 9. read to me every question and instruction on this application and my answer to every question in [fillable field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 10., [fillable field], prepared this application for me based only upon information I provided or authorized. [Page 11] Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Applicant’s Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.
Pages 10-11, Part 6. Contact Information, Certification, and Signature of the Interpreter	Part 6. Contact Information, Certification, and Signature of the Interpreter 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 (if any) 3.g. Postal Code (if any) 3.h. Country (if any) Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address [page 11] Interpreter 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 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 11] Part 9. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 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 Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [fillable field], which is the same language specified in Part 8., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question and answer on the application, including the Applicant’s Certification, and has verified the accuracy of every answer. [Page 12] Interpreter’s Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 11, Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant	Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other than the Applicant Preparer's Full Name 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 Name Preparer'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 (if any) 3.g. Postal Code (if any) 3.h. Country (if any) Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. 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. I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends/does not extend beyond the preparation of this form. Preparer's Declaration 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 12] Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) Preparer'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 Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer’s Statement 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States with this application. Preparer’s Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant’s Certification, and that all of this information is complete, true and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer’s Signature 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
		[Page 13] Part 11. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your 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; 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. [Fillable Field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable Field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable Field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable Field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable Field]

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