Form I-821 Application for Temporary Protected Status

USCIS
Form I-821

Application for Temporary Protected Status
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0043
Expires 03/31/2019

For USCIS Use Only
Receipt

Action Block

Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:

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Remarks

Received:
Sent:

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)

► START HERE - Type or print in black ink.

Part 1. Type of Application (select one)

Are you also filing a request for employment authorization?

NOTE: Select the box for Item Number 1.a., 1.b., or 2. If
applicable, select the box for Item Number 3.a. or 3.b. For
Item Number 4., enter the name of the designated TPS country.

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.

1.a.

1.b.

This is my initial (first time) application for
Temporary Protected Status (TPS). I do not currently
have TPS.

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.

4.

Name of designated TPS country under which you are
applying.

Part 2. Information About You

Your Full Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

If you selected Item Number 1.b., please indicate who
granted you TPS.
USCIS
Immigration Judge/Board of Immigration Appeals

Form I-821 08/21/17 N

Page 1 of 13

Part 2. Information About You (continued)

Other Information
7.

Other Names Used

Alien Registration Number (A-Number) (if any)
► A-

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)

8.

USCIS Online Account Number (if any)
►

9.

U.S. Social Security Number (if any)
►

10.

Date of Birth (mm/dd/yyyy)

2.c. Middle Name

Other Dates of Birth Used (if any)

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

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.

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3.c. Middle Name

11.a. Other Date of Birth
(mm/dd/yyyy)

U.S. Mailing Address

11.b. Other Date of Birth
(mm/dd/yyyy)

4.a. In Care Of Name

12.

Gender

13.

City/Town/Village of Birth

14.

Country of Birth

4.b. Street Number
and Name
4.c.

Apt.

Ste.

Flr.

4.d. City or Town

4.f.

ZIP Code

15.a.

Is your current mailing address the same as your physical
address (where you live)?
Yes
No

15.b.

If you answered "No" to Item Number 5., please provide your
physical address below.

15.d.

U.S. Physical Address

Apt.

Country or Countries of Citizenship or Nationality (if any)
(List all countries that apply.)
16.b.

Ste.

Flr.

16.c.
16.d.

6.c. City or Town
6.d. State

15.c.

16.a.

6.a. Street Number
and Name
6.b.

Female

Countries of Residence (Before entering the U.S.)

4.e. State
5.

Male

6.e. ZIP Code

Your Marital Information
17.

Current Marital Status (Select only one box)
Single, Never Married

Married

Divorced

Widowed

Separated

Marriage Annulled

Other
Form I-821 08/21/17 N

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Part 2. Information About You (continued)

Your Current Immigration Status

18.

31.

Current Immigration Status or Lack of Status

32.

Are you now or were you EVER in immigration
proceedings?
Yes

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)

Type of Proceedings (Select all boxes that apply):
33.a.

Immigration Court (before an Immigration Judge)

33.b.

Board of Immigration Appeals (BIA)

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.

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.

If you answered "Yes" to Item Number 32., provide the
following information.

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Place of Last Entry into the United States
21.

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.)

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.

26.

No

Present

Travel Document Number (if any)

Part 3. Biographic Information

27.

Additional Passport or Travel Document Number

1.

Ethnicity (Select only one box)
Hispanic or Latino

28.

Additional Passport or Travel Document Number

Not Hispanic or Latino
2.

29.

30.

Country of Issuance for most recent Passport or Travel
Document
Expiration Date for most recent Passport or Travel
Document (mm/dd/yyyy)

Form I-821 08/21/17 N

Race (Select all applicable boxes)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

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Part 3. Biographic Information (continued)

Mailing Address of Spouse

3.

Height

4.a. Street Number
and Name

4.

Weight

5.

Eye Color (Select only one box)

Feet

Inches
Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

4.d. State
4.f.

Ste.

Flr.

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

Hair Color (Select only one box)

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Bald (No hair)

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

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.

Apt.

4.c. City or Town

Unknown/Other
6.

4.b.

USCIS Online Account Number (if any and if known)

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

►

2.

A-Number (if any and if known)

9.

If you know, has your current spouse EVER had TPS?
Yes

► A-

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

3.c. Middle Name

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.

Form I-821 08/21/17 N

No

Is your spouse's TPS still valid? (if known)
Yes
No
I Do Not Know

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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)

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)

First Marriage

A-

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

14.

Date of Birth of Former Spouse
(mm/dd/yyyy)

15.

Date of Death if Former Spouse Deceased
(mm/dd/yyyy)

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1.c. Middle Name
2.

Nationalities of Former Spouse

Dates of Marriage to Former Spouse
16.a. From (mm/dd/yyyy)

3.

A-Number of Former Spouse (if any and if known)
► A-

4.

Date of Birth of Former Spouse
(mm/dd/yyyy)

5.

Date of Death if Former Spouse Deceased
(mm/dd/yyyy)

How Marriage Ended (for example, divorce, widowed,
annulled)

18.

Did or does this former spouse have TPS (if known)?
No

I Do Not Know

If yes, what dates did he or she have TPS (if known)?

6.a. From (mm/dd/yyyy)

19.a. From (mm/dd/yyyy)

6.b. To (mm/dd/yyyy)

8.

17.

Yes

Dates of Marriage to Former Spouse

7.

16.b. To (mm/dd/yyyy)

19.b. To (mm/dd/yyyy)

How Marriage Ended (for example, divorce, widowed,
annulled)

Did or does this former spouse have TPS (if known)?
Yes

No

I Do Not Know

19.c.

Present

19.d.

I do not know the dates

20.

Is this former spouse currently applying for or reregistering for 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 reregistering for TPS (if known)?
Yes

Form I-821 08/21/17 N

No

I Do Not Know

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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.

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)
► A-

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

11.

Date of Birth (mm/dd/yyyy)

1.c. Middle Name

12.a. Street Number
and Name

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

2.

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Mailing Address

USCIS Online Account Number (if any and if known)
►

3.

4.

12.c. City or Town

Date of Birth (mm/dd/yyyy)

12.f. Province

Apt.

Flr.

12.e. ZIP Code

12.h. Country

Ste.

Flr.

5.c. City or Town
5.d. State

12.d. State

Ste.

12.g. Postal Code

5.a. Street Number
and Name

5.f.

Apt.

Alien Registration Number (A-Number) (if any and if
known)
► A-

Mailing Address

5.b.

12.b.

5.e. ZIP Code

Province

5.g. Postal Code

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 reregistering for TPS (if known)?
Yes
No

5.h. Country

Part 7. Eligibility Standards
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.

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):

If you know, is this child currently applying for or reregistering for TPS (if known)?
Yes
No

Form I-821 08/21/17 N

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Part 7. Eligibility Standards) (continued)

Your Immigration and Criminal History

1.b. I entered the United States on the following date, and
have resided in the United States since that time.

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.

(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?
Yes
No
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.

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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?
Yes

6.

7.

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.

No

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.

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.

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?
Yes

No

8.b. Any misdemeanor committed in the United States?
Yes
Form I-821 08/21/17 N

No
Page 7 of 13

Part 7. Eligibility Standards (continued)
8.c.

Any particularly serious crime committed either in or
outside the United States?
Yes
No

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?
Yes
No
9.b. Have you EVER committed serious nonpolitical crimes
outside of the United States prior to your arrival in the
United States?
Yes
No
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 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?
Yes
No
13.b. Any activity to violate or evade any law prohibiting the
export from the United States of goods, technology, or
sensitive information?
Yes
No

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Yes

No

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)?
Yes

No

10.b. A violation of any law relating to a controlled substance
as defined in section 102 of the Controlled Substances
Act?
Yes
No
10.c. A conspiracy to violate any law relating to a controlled
substance as defined in section 102 of the Controlled
Substances Act?
Yes
No
11.

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?
Yes
No

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?
Yes
No

12.a. Have you EVER trafficked in or are you NOW
trafficking in any controlled substance?
Yes

No

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?
Yes

No

12.c. Are you the spouse or child of an alien who unlawfully
trafficked in any controlled substance?
Yes

No

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?
Yes

Form I-821 08/21/17 N

No

13.c. Any other unlawful activity in the United States?
Yes

No

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?
Yes

No

14.a. Have you EVER or are you NOW engaged in terrorist
activities?
Yes
No
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?
Yes
No
14.c. Have you EVER been or are you NOW a member of the
Communist or other totalitarian party, except when
membership was involuntary?
Yes
No
14.d. Have you EVER participated in Nazi persecution or
genocide?
Yes
No
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?
Yes
No
15.b. Cited, charged, or indicted, for breaking or violating any
law or ordinance, excluding minor traffic violations?
Yes

No

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?
Yes
No

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Part 7. Eligibility Standards (continued)
16.

Have you EVER been the beneficiary of a pardon,
amnesty, rehabilitation decree, other act of clemency, or
similar action?
Yes
No

17.

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

18.a. Have you EVER, within the past 10 years, or are you
NOW engaged in prostitution or procurement of
prostitution?
Yes
No
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?

Yes

24.
25.

Have you EVER entered the United States as a
stowaway?
Yes

No

No

20.b. Have you EVER voluntarily departed the United States
under an order of removal?
Yes
No
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?
Yes
No

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?
Yes
No

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?
Yes
No
Have you EVER assisted any other person to enter the
United States in violation of the law?
Yes
No

No

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?
Yes

No

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)?
Yes
No

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?
Yes
No

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?
Yes
No

Have you EVER been or do you intend to be involved in
any other commercial vice?
Yes
No

20.a. Have you EVER been ordered removed, and been
deported from the United States?
Yes

22.

23.c. Are you NOW or have you EVER been a drug abuser or
drug addict?
Yes
No

No

18.c. Have you EVER, within the past 10 years, received, in
whole or in part, the proceeds of prostitution?

21.

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?
Yes
No

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Yes

19.

23.a. Do you NOW have a communicable disease of public
health significance?
Yes
No

Yes

No

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?

Yes

No

30.b. Killing any person?

Yes

No

30.c. Intentionally and severely injuring any person?
Yes

No

30.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes

No

30.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

Form I-821 08/21/17 N

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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?

Part 7. Eligibility Standards (continued)
Have you EVER:
31.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerrilla group,
militia, or insurgent organization?
Yes
No
31.b. Served or worked in any prison, jail, prison camp,
detention facility, labor camp, or any other situation that
involved detaining persons?
Yes
No
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?

34.

No

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?
Yes
No
Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

Yes

Have you EVER unlawfully voted in a United States
Federal, state, or local election?
Yes
No

36.

Have you EVER claimed to be a U. S. citizen (in writing
or in any other way)?
Yes
No

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?
Yes
No
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?
Yes
No

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?
Yes

Yes

39.b. Are you NOW or have you EVER been a knowing aider,
abettor, assister, conspirator, or colluder with others in
money laundering?
Yes
No
40.

41.

No

Has an immigration judge or the Board of Immigration
Appeals EVER determined that you filed a frivolous
asylum application in the past?
Yes
No

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

No

38.c. Are you NOW the spouse or child of an alien who
committed or conspired to commit human trafficking
offenses?
Yes
No

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?
Yes

No

38.b. Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded with a human trafficker?

No

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?
Yes
No

No

35.

No

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?

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Yes

33.

Yes

answer to every question in
a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 10.,
prepared this application for me based only upon
information I provided or authorized.

Form I-821 08/21/17 N

Page 10 of 13

Part 8. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
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)

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)

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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

Interpreter's Mailing Address

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

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)

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.

6.

Interpreter's Email Address (if any)

Applicant's Signature

Interpreter's Certification

6.a. Applicant's Signature

I certify, under penalty of perjury, that:

3) All of this information was complete, true, and correct
at the time of filing.

I am fluent in English and
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.

Form I-821 08/21/17 N

,

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 11 of 13

Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)

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.

Interpreter's Signature
7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

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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.

3.d. State

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

Ste.

Flr.

3.c. City or Town

3.f.

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.

8.b. Date of Signature (mm/dd/yyyy)

3.e. ZIP Code

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)

Form I-821 08/21/17 N

Page 12 of 13

5.a. Page Number

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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number
3.d.

4.a. Page Number
4.d.

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

Form I-821 08/21/17 N

4.c. Item Number

7.a. Page Number
7.d.

Page 13 of 13