I-821-013-Online Filing Copydeck-Initial TPS w Concurrent I-765

Application for Temporary Protected Status

I-821-013-Online Filing Copydeck-Initial TPS w Concurrent I-765

OMB: 1615-0043

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1615-0043 can be found here:

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myUSCIS copy deck
Form I-821 Application for Temporary Protected Status
Form I-765 Application for Employment Authorization
OMB control number 1615-0043
Baseline version: 07/03/2019

I-821 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Heading
Sub-Heading
I-821, Application for
Temporary Protected Status
(TPS)

Body Text
If you are an eligible national of certain countries that the Secretary of Homeland Security (Secretary) has designated for Temporary Protected
Status (TPS) or a person without nationality who last habitually resided in the designated country, then you may apply for TPS by filing Form I-821,
Application for Temporary Protected Status. This form is also used if you have TPS and are filing for TPS re-registration.

Link
https://www.uscis.gov/humanitarian/temporary-protected-status

CTA

Notes
Form I-821 Instructions, page 1

Do not use Form I-821 to request Consideration Of Deferred Action for Childhood Arrivals (DACA). Form I-821D must be used to request DACA.
Review countries currently designated for TPS.

Before You Start Your
Application

Eligibility

You may file Form I-821 online only if you are an eligible national of Burma, Haiti, Syria, or Venezuela or an individual without nationality who last
habitually resided in Burma, Haiti, Syria or Venezuela filing an initial application for TPS. All other TPS applicants and re-registrants must submit a
paper Form I-821. All other applicants and re-registrants must submit a paper Form I-821.

https://www.uscis.gov/i-821

Form I-821 Instructions, page 1-2;
12

To be eligible for TPS, you must be admissible to the United States as an immigrant under the applicable grounds in INA section 212(a), with certain
exceptions.
We may grant discretionary waivers of certain inadmissibility grounds for humanitarian purposes, to assure family unity, or because it is otherwise
in the public interest. However, we cannot waive some inadmissibility grounds, by law, including certain criminal grounds in INA sections 212(a)(2)(AC) and national security, terrorism- related, and persecution grounds in INA sections 212(a)(3)(A-C, E). If you are inadmissible on grounds that can be
waived, you may be able to obtain a discretionary waiver.
Each person seeking TPS must apply for themselves on a separate Form I-821. There is no derivative TPS status, meaning that your spouse, children
or parents cannot obtain TPS as a result of your approval for TPS. They must each qualify for TPS individually. However, we may accept late initial
TPS applications from certain individuals who had a qualifying relationship to a spouse or child during the initial registration period for the TPSdesignated country and that relative is also currently eligible for TPS. Even where such a relationship exists, the applicant must still meet all other TPS
eligibility requirements before we may grant TPS.
You may submit this form with Form I-765 online if you also want to request an Employment Authorization Document (EAD). If you request an EAD
in Form I-821, we will add Form I-765 for you to complete after you sign your Form I-821.
Note: If you were ever convicted of or ever committed a “particularly serious crime” that constitutes a “danger to the community of the United
States,” or there are serious reasons for believing that you have committed “serious nonpolitical crimes” outside of the United States before your
arrival in this country, you cannot be granted TPS. We will make the determination as to whether your crimes fall into either of these categories.

Fee

Fee: $50. If you are 14 years of age or older, you must also pay an $85 biometric services fee.

Form I-821 Instructions, page 14

Note: You cannot use a fee waiver if applying online.
Refund policy:
USCIS does not refund fees, regardless of any action we take on your application, petition or request, or how long USCIS takes to reach a decision. By
continuing this transaction, you acknowledge that you must submit fees in the exact amount and that you are paying the fees for a government
service.
Please refer to the instructions for the form(s) you are filing for additional information or you may call the USCIS Contact Center at 800-375-5283.
For TTY (deaf or hard of hearing) 800-767-1833.

After You Submit Your
Application

Completing Your Form
Online

Documents you may need

We will automatically determine which documents you should provide us as you fill out your application. At the time of filing, you must submit all
evidence and supporting documentation listed.

Content specific to digital
environment

Biometric services appointment

USCIS may require that you appear for an interview or provide fingerprints, photograph, and/or signature at any time to verify your identity, obtain
additional information, and conduct background and security checks, including a check of criminal history records maintained by the Federal Bureau
of Investigation (FBI), before making a decision on your application, petition, or request. After USCIS receives your application and ensures it is
complete, we will inform you in writing or by email notice if you e-file your application, if you need to attend a biometric services appointment. If an
appointment is necessary, the notice will provide you the location of your local or designated USCIS Application Support Center (ASC) and the date
and time of your appointment or, if you are currently overseas, instruct you to contact a U.S. Embassy, U.S. Consulate, or USCIS office outside the
United States to set up an appointment.

Content specific to digital
environment

Track your case online

After you submit your form, you can track its status through your USCIS account. Sign in to your account often to check your case status and read
any important messages from USCIS.

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environment

Respond to requests for information

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environment

Receive your decision

The decision on Form I-821 involves a determination of whether you have established eligibility for the immigration benefit you are seeking. USCIS
will notify you of the decision in writing.

Filing online

Submitting your application online is the same as mailing in a completed paper form. They both gather the same information.

Complete the Getting Started section first

You should answer all questions in the Getting Started section first so we can best customize the rest of your online form experience.

Provide as many responses as you can

You should provide as many responses as you can. Incomplete fields or sections and missing information can slow down the process after you
submit your form.
We will automatically save your information when you select next to go to a new page or navigate to another section of the form. We will save your
information for 30 days from today, or from the last time you worked on the form.
After you start your form, you can sign in to your account to continue where you left off.

We will automatically save your responses
How to continue filling out your form

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821 - Application Overview

I-821 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Heading

Sub-Heading

Body Text

DHS Privacy Notice

AUTHORITIES: The information requested on this application, and the associated evidence, is collected under INA sections 101 and 244.

Form I-821 Instructions, page 16

PURPOSE: The primary purpose for obtaining the requested information on this application is to determine whether you have established eligibility
for TPS, if you have not yet been granted TPS. DHS will use the information you provide to grant or deny the benefit you are seeking.

Form I-821 Instructions, page 16

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your Social Security
number (if applicable), and any requested evidence, may delay a final decision or result in denial of your application.

Form I-821 Instructions, page 16

Form I-821 Instructions, page 17

Paperwork Reduction Act

Link

CTA

Notes

U.S. Citizenship and Immigration Services
Office of Policy and Strategy, Regulatory Coordination Division
5900 Capital Gateway Drive, Mail Stop #2140
Camp Springs, MD 20588-0009
Do not mail your completed Form I-821 to this address.
OMB No. 1615-0043
Expires: 7/31/2022
Security reminder

If you do not work on your application for more than 30 days, we will delete your data in order to prevent storing personal information indefinitely.

Start

Content specific to digital
environment

821 - Application Overview

I-821: GETTING STARTED
The Getting Started step is the first part of the form that the applicant will complete. Questions relating to the applicant's basis for eligibility (if applicable) and questions about the applicant's preparer/interpreter (if any) should be grouped in the Getting Started step of the form and should be organized by the appropriate section. This step and section structure will inform the navigation
and sub-navigation for the form.
Primary Nav

Secondary Nav

Getting Started Reason for applying

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

1.1.a

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

Radio

Required field

This is my re-registration application for TPS. I currently
have TPS, and am applying to re-register.

Radio

part of second release; will display if reregistration application

USCIS

Radio

part of second release; will display if reregistration application

Immigration Judge/Board of Immigration Appeals

Radio

part of second release; will display if reregistration application

What is your reason for applying?

1.1.b
(If 1.1.b)
1.2

1.3.a

Who granted you TPS?

Are you also filing a request for employment authorization? Yes, I am requesting an Employment Authorization
Document (EAD), and I am filing Form I-765, Application
for Employment Authorization, together with my Form I821.

1.3.b

1.4

Preparer and
interpreter information

(IF YES TO PREPARER
QUESTION) Preparer
information

No, I am not currently requesting an EAD.

What is the name of the designated TPS country under
which you are applying?

(IF YES) Is a preparer assisting you with completing this
application?

Yes/No

Radio

(IF YES) Is an interpreter assisting you with completing this
application?

Yes/No

Radio

10.1.b

What is your preparer's full name?

Given name (first name)

Text

10.1.a
10.2

What is your preparer's business or organization name?

Family name (last name)

Text
Text

What is your preparer's mailing address?

My preparer is not part of a business or organization.
Country

Checkbox
Dropdown

What is your preparer's contact information?

Address line 1
Address line 2
City or town
State/Province
ZIP code/Postal code
Daytime phone number

Text
Text
Text
Dropdown/Text
Text
Text

9.1.b

What is your interpreter's full name?

Mobile telephone number
My preparer does not have a mobile telephone number
Email address
My preparer does not have an email address.
Given name (first name)

Text
Checkbox
Text
Checkbox
Text

9.1.a
9.2

What is your interpreter's business or organization name?

Family name (last name)

Text
Text

9.3

What is your interpreter's mailing address?

My interpreter is not part of a business or organization.
Country

Checkbox
Dropdown

What is your interpreter's contact information?

Address line 1
Address line 2
City or town
State/Province
ZIP code/Postal code
Daytime telephone number

Text
Text
Text
Dropdown/Text
Text
Text

10.6
(IF YES TO
INTERPRETER)
Interpreter information

Dropdown

Radio

10.5

9.4
9.5

Notes

Radio

Yes/No

10.4

Help Text

Radio

Is someone assisting you with completing this application?

10.3.a.10.3.h.

Instructional Text

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A preparer is anyone who completes or helps you complete all or
part of your application using information and answers that you
provide.
An interpreter is anyone who translates or helps you translate all
or part of your application using information and answers that
you provide.

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Street number and name
Apartment, suite, unit, or floor

Mobile telephone number
Text
My interpreter does not have a mobile telephone number Checkbox

9.6
What language is your interpreter using to interpret this
application for you?

Email address
My interpreter does not have an email address.

Text
Checkbox
Text

821 - Getting Started

I-821: ABOUT YOU

The About You step is the second part of the paper form that the applicant will complete. Questions relating to the applicant's personal information should be grouped in the About you step of the form and should be organized by the appropriate section. This step and section structure will inform the navigation and subnavigation for the form. Personal information questions include questions about the applicant's name, contact information, immigration information, demographics, school and employment, military service, requests for accommodations, etc.
Primary Nav

Secondary Nav

About You

Your name

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

2.1.b

Given name (first name)

Text

Middle name
Family name (last name)
Yes/No

Text
Text
Radio

Given name (first name)

Text

Middle name
Family name (last name)
Daytime telephone number

Text
Text
Text (9 digits)

8.4

Mobile telephone number (if any)

Text (9 digits)

This is the same as my daytime
telephone number.
Email address
In care of name (if any)

Checkbox

8.5
2.4.a

2.1.c
2.1.a

2.2.b

Your contact
information

2.2.c
2.2.a
8.3

2.4.b
2.4.c
2.4.d
2.4.e
2.4.f
2.5
2.6.a

When and where
you were born

2.6.b
2.6.c
2.6.d
2.6.e
2.10

What is your current legal name?

Have you used any other names since
birth?
(If yes)

How may we contact you?

What is your current U.S. mailing
address?

Address line 1
Address line 2
City or town
State
ZIP code
Is your current mailing address the same Yes/No
as your physical address?
(If no) Where in the United States do
Address line 1
you live?
Address line 2
City or town
State
ZIP code
What is your date of birth?
(mm/dd/yyyy)

2.11.a-b

Describe yourself

(mm/dd/yyyy)

Instructional Text

Help Text

Your current legal name is the name on your birth
certificate, unless it changed after birth by a legal
action such as marriage or court order. Do not provide
any nicknames here.

Other names used may include nicknames, aliases,
and maiden names.
Provide the other names you have used.

Text
Text

We will use your current mailing address to contact
you throughout the application process. We may not
be able to contact you if you do not provide a
complete and valid address. Please provide a U.S.
address only.
Street number and name
Apartment, suite, unit, or floor

Text
Text
Text
Dropdown
Text
Radio
Text

Street number and name

Text
Text
Dropdown
Text
Date

Apartment, suite, unit, or floor

Date

Notes

List all other dates of birth you have ever
used.

2.13

What is your city, town, or village of
birth?

2.14
2.12

What is your country of birth?
What is your gender?

3.10

What is your ethnicity?

Hispanic or Latino
Not Hispanic or Latino

Radio

Hispanic or Latino refers to a person of Cuban,
Mexican, Puerto Rican, South or Central

3.2.

What is your race?

White

Checkbox

Select all that apply. Your race is different
from your ethnicity and should reflect your
geographical origins.

similar to other names used.

Text

Male/Female

Dropdown
Radio

White
A person having origins in any of the original peoples
of Europe, the Middle East, or North Africa.

821 - About You

I-821: ABOUT YOU

Secondary Nav

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

Asian

Checkbox

Instructional Text

Help Text

Notes

Asian
A person having origins in any of the original peoples
of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.

Black or African American

American Indian or Alaska Native

Checkbox

Black or African American

Checkbox

A person having origins in any of the black racial
groups of Africa.
American Indian or Alaska Native
A person having origins in any of the original peoples
of North and South America (including Central
America), and who maintains tribal affiliation or

Native Hawaiian or Other Pacific
Islander

Checkbox

A person having origins in any of the original peoples
of Hawaii, Guam, Samoa, or other Pacific Islands.

3.3.

What is your height?

Feet/Inches

Dropdown

3.4.

What is your weight?

Pounds

Text

3.5.

What is the color of your eyes?

Black/Blue/Brown/Gray/Green/Haze Dropdown
l/Maroon/Pink/ Unknown/other

3.6

What is the color of your hair?

Bald/Black/Blonde/Brown/Gray/Red Dropdown
/Sandy/White/other

Where you have
lived

2.15.a-d

What countries did you live in before
coming to the United States?

Dropdown

Your immigration
information

2.16.a-d

What is your country of citizenship or
nationality?

Dropdown

2.19

When did you last enter the United
States?
Where did you last enter the United
States?

2.21
2.22.a.

2.22.b

2.20.

2.23

Your immigration
information page 2

2.24

2.24
2.25
2.26

mm/dd/yyyy

Date

Port of entry

Dropdown?

City or town

Text

State

Dropdown

What was your immigration status
when you last entered the United
States?
What is your Form I-94 ArrivalDeparture Record Number (if any)?
What is the expiration date of the
authorized stay shown on your Form I94 or Form I-95?
Duration of Status
What is the passport number of your
most recently issued passport (if any)?
What is your travel document number
(if any)?

Native Hawaiian or Other Pacific Islander

List all countries where you are currently a
citizen or national. If you are stateless, choose
"Stateless."

User will be able to input multiple
countries (at least four based on paper
form). It will be a small table.
User will be able to input multiple
countries (at least four based on paper
form). It will be a small table

Text

11 character
restricted
text
mm/dd/yyyy

Date

Checkbox
Text
Text

821 - About You

I-821: ABOUT YOU

Secondary Nav

Tertiary Nav

Paper Form Question
Question
2.29
2.30.

2.27-2.28

Immigration status

Sub-Question

Field Type

What country issued your most recent Country
passport or travel document?
What is the expiration date of your most (mm/dd/yyyy)
recent passport or travel document?

Dropdown

What other passport or travel document
numbers do you have (if any)?

2.31

What is you current immigration status
or lack of status?
2.32
Are you now or were you ever in
Yes/No
immigration proceedings?
(If Yes to
What type of proceedings were you in Immigration court (before an
2.32) 2.33.a or are you currently in? Select all that
immigration judge)
apply.

2.33.b
2.33.c

(If Yes to
2.32) 2.34
(If 2.33c
selected)
2.35

Other information

2.36.a
2.36.b
2.36.c
2.7

2.9

2.8

Instructional Text

Help Text

Notes

Date

Text
Text

Checkbox

List the passport or travel document numbers
for all additional documents you have.

Small table

If your proceedings are ongoing, leave the
"To" date blank. List any other immigration
proceedings in the “Additional Information”
section. Include the type of proceedings you
were in, the dates, and the location.

Board of Immigration Appeals (BIA) Checkbox
I am no longer in Department of
Checkbox
Justice (DOJ) or Department of
Homeland Security (DHS)
immigration proceedings, but I am
or was in Federal court proceedings
regarding immigration issues.
Where were your DOJ and/or DHS
proceedings held, or are currently being
held (if applicable)?
Where were your federal court
proceedings regarding immigration
issues held, or are currently being held
(if applicable)?
When did the proceedings take place? From
To
Present
What is your A-Number?
A-Number

Text

I do not have or know my A-Number.
What is your U.S. Social Security
number, if any?
I do not have or know my U.S. Social
Security number.
What is your USCIS Online Account
Number?

Checkbox
Text (9 digits)

I do not have or know my USCIS Online
Account Number.

Checkbox

Text

Date
Date
Checkbox
Text (9 digits)

Checkbox
Text (12
digits)

Providing your unique USCIS Online Account The phrase "certain paper forms" would have a tooltip
Number (OAN) helps us manage your account. that would list the forms: "I-90, I-130, I-485, I-821, I821D, N-336, N-400, N-565, N-600, N-600K"
You may already have an OAN if you
previously filed certain paper forms and
received an Account Access Notice in the mail.
You can find the OAN at the top of the notice;
it is not the same as an A-Number.

821 - About You

I-821: YOUR FAMILY

The Your Family step is for forms that collect in-depth information about an applicant's family. Questions relating to the applicant's family should be grouped in the Your family step of the form and should be organized by the appropriate section. This
step and section structure will inform the navigation and sub-navigation for the form. This includes questions about the applicant's marital status, their current spouse, any prior marriages, children, parents, etc.
Primary Nav Secondary Nav
Your Family Marital status

Tertiary Nav Paper Form Question
Question
2.17

2.17
2.18

Sub-Question

Field Type

Instructional Text

Complete this section only if you are filing a
late initial application for TPS. Provide
information about your spouse, if any.
What is your spouse's legal
name?

4.3.b
4.3.c

What is your spouse's
current mailing address?

4.4.e

4.1

Given name (first name)

Text

part of second release;
will display if reregistration application

Your spouse's legal name is the name on
their birth certificate, unless it changed after
birth by a legal action such as marriage or
court order. Do not provide a nickname here.

Middle name (if applicable) Text

4.4h
4.4.a
4.4.b
4.4.c
4.4.d

4.2

Notes

What is your current marital Single, never
Radio
status?
married/Married/Divorced
/Widowed/Separated/Marr
iage annulled/Other
(IF OTHER) Provide an
Text
explanation.
(If Married OR Separated)
Month/Day/Year
Date
On what date did you marry
your spouse?

(IF Married or Separated)
Your spouse

4.3.a

Help Text

What is your spouse's ANumber?

What is your spouse's USCIS
Online Account Number?

Family name (last name)

Text

My spouse's current
Checkbox
mailing address is the same
as my mailing address.
Country
Address line 1
Address line 2
City or town
State/Province or region
(FOR FOREIGN ADDRESS)
ZIP code/Postal code (FOR
FOREIGN ADDRESS)

Text
Text
Text
Text
Dropdown

My spouse does not have
or know their A-Number.

Checkbox

Text
Text

Providing your unique USCIS Online Account
Number (OAN) helps us manage your
account. You may already have an OAN if you
previously filed certain paper forms and
received an Account Access Notice in the
mail. You can find the OAN at the top of the
notice; it is not the same as an A-Number.

The phrase "certain
paper forms" would
have a tooltip that
would list the forms: "I90, I-130, I-485, I-821, I821D, N-336, N-400, N565, N-600, N-600K"

821 - Your Family

I-821: YOUR FAMILY

Tertiary Nav Paper Form Question
Question

4.5
4.7
4.8.d
4.8.a
4.8.b/c
4.9
4.10.a
4.10.b
4.10.c
4.10.d

Your former spouses

5.1.b

What is your spouse's date
of birth?
Where were you and your
spouse married?

If you know, has your
spouse ever had TPS?
(IF YES) When did your
spouse have TPS?

5.3

5.4
5.5

5.6.a-b
5.7

Field Type

Instructional Text

Help Text

Notes

My spouse does not have
or know their USCIS Online
Account Number.
Month/Day/Year
Date
Place of marriage

Text

Country
City or town
State/Province or region
(FOR FOREIGN ADDRESS)
Yes/No

Dropdown
Text
Dropdown/T
ext
Radio

From

Date

To
Present
I do not know the dates
(If YES) Is your spouse's TPS Yes/No/I do not know
still valid?
Former Spouses

Date
Checkbox
Checkbox
Radio

What is your former
spouse's legal name?

Text

5.1.c
5.1.a
5.2

Sub-Question

Given name (first name)

Complete this section only if you are filing a
late initial application for TPS. Provide
information about your former spouses, if
any.
Your former spouse's legal name is the name
on their birth certificate, unless it changed
after birth by legal action such as marriage or
court order. Do not provide a nickname here.

part of second release;
will display if reregistration application

Middle name (if applicable) Text

What are your former
spouse's nationalities?
What is your former
spouse's A-Number?

Family name (last name)

Text
Text

Provide your former spouse’s nationality
or nationalities, if more than one.

Text
My former spouse does
not have or know their ANumber.
Month/Day/Year

What is your former
spouse's date of birth?
What is the date of your
former spouse’s death (if
deceased)?
When were you married to From/To
your former spouse?
How did this marriage end? Annulled/Divorced/Spouse
deceased/Other
(IF OTHER) Provide an
explanation.

Checkbox

Date
Date

Date
Radio
Text

821 - Your Family

I-821: YOUR FAMILY

Tertiary Nav Paper Form Question
Question
5.8

5.9.a
5.9.b
5.9.c
5.9.d
5.10.

Your children

6.1.b

6.1.c
6.1.a
6.4

6.5.h
6.5.a
6.5.b
6.5.d/f
6.5.e/g
6.2

Did your former spouse
have TPS or do they
currently have TPS?
(IF YES) When did your
former spouse have TPS?

(If YES) Is your former
spouse currently applying
for TPS or re-registering for
TPS?
Children Information

What is your child's legal
name?

Sub-Question

Field Type

Yes/No/I do not know

Radio

From

Date

To
Present
I do not know the dates
Yes/No/I do not know

Date
Checkbox
Checkbox
Radio

Instructional Text

Complete this section only if you are filing a
late initial application for TPS. Provide
information about your children, if any.
Given name (first name)

Text

Help Text

Notes

part of second release;
will display if reregistration application

Your child's legal name is the name on their
birth certificate, unless it changed after birth
by legal action such as marriage or court
order. Do not provide a nickname here.

Middle name (if applicable) Text
Family name (last name)
What is your child's date of Month/Day/Year
birth?
What is your child's current
mailing address?
My child's current mailing
address is the same as my
mailing address.
Country
Address line 1
Address line 2
State/Province or region
(FOR FOREIGN ADDRESS)
ZIP code/Postal code (FOR
FOREIGN ADDRESS)
What is your child's USCIS
Online Account Number?

My child does not have or
know their USCIS Online
Account Number.

Text
Date

Checkbox

Text
Text
Text
Text
Dropdown
Text (12
digits)

The phrase "certain
paper forms" would
have a tooltip that
would list the forms: "I90, I-130, I-485, I-821, I821D, N-336, N-400, N565, N-600, N-600K"

Checkbox

821 - Your Family

I-821: YOUR FAMILY

Tertiary Nav Paper Form Question
Question
6.3

6.6a

6.6.b
6.7

What is your child's ANumber?

If your child had TPS or
currently has TPS, enter the
dates of their TPS, if known.

Is your child currently
applying for TPS or reregistering for TPS, if
known?

Sub-Question

Field Type

Instructional Text

Help Text

Notes

Text
My child does not have or
know their A-Number.
From

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To
Yes/No

Date
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Date

821 - Your Family

I-821: BASIS OF ELIGIBILITY

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Paper Form
Question

Question

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Help Text

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.

Basis of Eligibility

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 "Additional Information" section.
Immigration eligibility

7.28

(If Yes to 7.28)
7.23.a
(If Yes to 7.23.a)
7.23.b

(If Yes 7.23.b)
Immigration eligibility 7.1.a
page 2
7.1.b
7.1.c

(If Yes to 7.1.c)
Immigration eligibility
page 3

Provide an explanation.
What is your country of nationality?
I entered the United States on the following date, and
have resided in the United States since that time.
Have you ever traveled to and entered a country other than your
country of nationality or last habitual residence before you last
entered the United States?
Countries You Traveled To

(If Yes to 7.1.c) 7.2 What country did you travel to and enter?
(If Yes to 7.1.c) 7.3. When were you in this country?
(If Yes to 7.1.c) 7.4 What was your immigration status in this country, if any?

7.5
(If Yes to 7.5) 7.6
(If Yes to 7.5)7.7
Citizenship claims and
immigration violations

Are you now the guardian of, and are you accompanying, another Yes/No
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?
Provide an explanation.
Do you now have a communicable disease of public health
Yes/No
significance?
Provide an explanation.
Do you now have or have you ever had a physical or mental
Yes/No
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?

7.35
(If Yes to 7.35)
7.36
(If Yes to 7.36)
7.20.a

Have you ever been offered any immigration status by another
country that you did not accept?
Provide the country or countries, the nature of the immigration
status you were offered, and the dates when it was offered.
Describe why you chose not to accept the immigration status
offered to you.
Have you ever unlawfully voted in a United States Federal, state, or
local election?
Provide an explanation.
Have you ever claimed to be a U.S. citizen (in writing or in any
other way)?
Provide an explanation.
Have you ever been ordered removed, and been deported from
the United States?

Radio

Text
Radio
Text
Radio

Text
Dropdown
mm/dd/yyyy

Date

Yes/No

Radio

If you have no nationality, enter the country where
you last habitually resided.

Provide information for each country you traveled to
and entered prior to entering the United States.

From/To

Dropdown
Date
Text?

Yes/No

Radio

Ex: citizen, legal permanent
resident, refugee, asylee,
visitor, student, temporary
resident, or no status.

Text
Text
Yes/No

Radio

Yes/No

Text
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Yes/No

Text
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821 - Basis of Eligibility

I-821: BASIS OF ELIGIBILITY

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Provide an explanation.
Text
Have you ever voluntarily departed the United States under an
Yes/No
Radio
order of removal?
Provide an explanation.
(If Yes to 7.20.b)
Text
(If Yes to 7.20.a or Have you re-entered the United States unlawfully at any time after Yes/No
Radio
7.20.b)7.20.c
you were deported or you voluntarily departed?
(If Yes to 7.20.c) Provide an explanation.
Text
(If Yes to 7.20.c) Has DHS reinstated your prior order of removal?
Yes/No/I do no Radio
7.20.d.
(If Yes to 7.20.d) Provide an explanation.
Text
Have you ever failed to attend or remain in attendance at any
7.20.e
Yes/No
Radio
immigration proceedings to determine your admissibility or
deportability?
(If Yes to 7.20.e) Provide an explanation.
Text
Has an immigration judge or the Board of Immigration Appeals
7.41
Yes/No
Radio
ever determined that you filed a frivolous asylum application in the
past?
Provide an explanation.
(If Yes to 7.41)
Text
Have you ever, by fraud or willfully misrepresenting a material fact, Yes/No
7.21
Radio
sought to obtain a visa or other documentation, admission to the
United States, or any other immigration benefit?
Provide an explanation.
(If Yes to 7.21)
Text
Have you ever assisted any other person to enter the
7.22
Yes/No
Radio
United States in violation of the law?
Provide
an
explanation.
(If Yes to 7,22)
Text
Citizenship claims and 7.24
Have you ever entered the United States as a stowaway?
Yes/No
Radio
immigration
violations page 2
Provide an explanation.
(If Yes to 7.24)
Text
Did the former Immigration and Naturalization Service (INS) ever Yes/No
7.25
Radio
impose, or has DHS ever imposed, civil monetary penalties on you
for producing or using false documentation to obtain an
immigration benefit?
Provide an explanation.
(If Yes to 7.25)
Text
Are you now subject to a final order for violation of section 274C Yes/No
7.26
Radio
(producing and/or using false documentation to unlawfully satisfy
a requirement of the Immigration and Nationality Act)?
Provide an explanation.
(If Yes to 7.26)
Text
Have you ever been or are you now a member of the Communist Yes/No
7.14.c
Radio
or other totalitarian party, except when membership was
involuntary?
(If Yes to 7.14.c) Provide an explanation.
Text
Have you ever participated in Nazi persecution or genocide?
7.14.d
Yes/No
Radio
Provide
an
explanation.
(If Yes to 7.14.d)
Text
Have
you
ever
ordered,
incited,
assisted,
or
otherwise
participated
7.9.a
Yes/No
Radio
in the persecution of any person on account of race, religion,
nationality, membership in a particular social group, or political
opinion?
Provide an explanation.
(If Yes to 7.9.a)
Text
Have you ever ordered, incited, called for, committed, helped with, Yes/No
7.30.a
Radio
or otherwise participated in acts involving torture or genocide?
(If Yes to 7.20.a)
7.20.b

Affiliations

(If Yes to 7.30.a)
7.30.b
(If Yes to 7.30.b)
7.30.c

Provide an explanation.
Have you ever ordered, incited, called for, committed, helped with, Yes/No
or otherwise participated in killing any person?
Provide an explanation.
Have you ever ordered, incited, called for, committed, helped with, Yes/No
or otherwise participated in intentionally and severely injuring any
person?

Text
Radio
Text
Radio

821 - Basis of Eligibility

I-821: BASIS OF ELIGIBILITY

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Question

(If Yes to 7.30.b)
7.14.a
(If Yes to 7.14.a)
7.30.d

Provide an explanation.
Have you ever or are you now engaged in terrorist activities?
Provide an explanation.
Have you ever ordered, incited, called for, committed, helped with,
or otherwise participated in any kind of sexual contact or relations
with any person who was being forced or threatened?
Provide an explanation.
Have you ever ordered, incited, called for, committed, helped with,
or otherwise participated in limiting or denying any person's ability
to exercise religious beliefs?
Provide an explanation.
Have you ever 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?
Provide an explanation.
Have you ever served or worked in any prison, jail, prison camp,
detention facility, labor camp, or any other situation that involved
detaining persons?
Provide an explanation.
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?
Provide an explanation.
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?

(If Yes to 7.30.d)
7.30.e

Affiliations page 2

(If Yes to 7.30.e)
7.31.a

(If Yes to 7.31.a)
7.31.b

(If Yes to 7.31.b)
7.32

(If Yes to 7.32)
7.33

Yes/No

Text
Radio
Text
Radio

Yes/No

Text
Radio

Yes/No

Text
Radio

Yes/No

Text
Radio

Yes/No

Text
Radio

Yes/No

Text
Radio

Yes/No

Provide an explanation.
Have you ever received any type of military, paramilitary, or
Yes/No
weapons training?
Provide an explanation.
Have you ever recruited, enlisted, conscripted, or used any person Yes/No
under 15 years of age to serve in or help an
armed force or group?
Provide an explanation.
Have you ever used any person under 15 years of age to take part Yes/No
in hostilities or to help or provide services to people in combat?

Text
Radio

(If Yes to 7.37.b)
7.40.

Provide an explanation.
Have you ever been responsible for or directly carried out
Yes/No
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?

Text
Radio

(If Yes to 7.40.)
7.12.c

Provide an explanation.
Are you the spouse or child of an alien who unlawfully trafficked in Yes/No
any controlled substance?
Provide an explanation.
Are you the spouse or child of an alien who assisted, abetted,
Yes/No
conspired, or colluded with others in the unlawful trafficking of
any controlled substance?
Provide an explanation.
Are you now the spouse or child of an alien who committed or
Yes/No
conspired to commit human trafficking offenses?
Provide an explanation.

Text
Radio

(If Yes to 7.33)
7.34
(If Yes to 7.34)
7.37.a

(If Yes to 7.37.a)
7.37.b

Affiliations page 3

Sub-Question Field Type

(If Yes to 7.12.c)
7.12.d

(If Yes to 7.12.d)
7.38.c
(If Yes to 7.38.c)

Instructional Text

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821 - Basis of Eligibility

I-821: BASIS OF ELIGIBILITY

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7.38.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?
Provide an explanation.
Have you ever been convicted of any felony committed in the
United States?
Provide an explanation.
Have you ever been convicted of any misdemeanor committed in
the United States?
Provide an explanation.
Have you ever been convicted of any particularly serious crime
committed either in or outside the United States?
Provide an explanation.
Have you ever been convicted of or have you ever committed acts
which constitute the essential elements of a crime (other than a
purely political offense)?
Provide an explanation.
Have you ever been convicted of or have you ever committed acts
which constitute the essential elements of a violation of any law
relating to a controlled substance as defined in section 102 of the
Controlled Substances Act?
Provide an explanation.
Have you ever been convicted of or have you ever committed acts
which constitute the essential elements of a conspiracy to violate
any law relating to a controlled substance as defined in section 102
of the Controlled Substances Act?
Provide an explanation.
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?
Provide an explanation.
Have you ever, whether in the United States or any other country
been arrested, for breaking or violating any law or ordinance,
excluding minor traffic violations?
Provide an explanation.
Have you ever, whether in the United States or any other country
been cited, charged, or indicted, for breaking or violating any law
or ordinance, excluding minor traffic violations?
Provide an explanation.
Have you ever, whether in the United States or any other country
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

Radio

Yes/No

Text
Radio

Yes/No

Tet
Radio

Yes/No

Text
Radio

(If Yes to 7.38.d)
7.8.a

Crimes and offenses

(If Yes to 7.8.a)
7.8.b
(If Yes to 7.8.b)
7.8.c
(If Yes to 7.8.c)
7.10.a

(If Yes to 7.10.a)
7.10.b

(If Yes to 7.10.b
7.10.c

(If Yes to 7.10.c)
7.11

Crimes and offenses
page 2

(If Yes to 7.11)
7.15.a

(If Yes to 7.15.a)
7.15.b

(If Yes to 7.15.b)
7.15.c

(If Yes to 7.15.c)
7.16
(If Yes to 7.16)
7.17
(If Yes to 7.17)
7.9.b

Crimes and offenses
page 3

(If Yes to 7.9.b)
7.13.a

Provide an explanation.
Have you ever been the beneficiary of a pardon, amnesty,
rehabilitation decree, other act of clemency, or similar action?
Provide an explanation.
Have you ever committed a serious criminal offense in the United
States and asserted immunity from prosecution?
Provide an explanation.
Have you ever committed serious nonpolitical crimes outside of
the United States prior to your arrival in the United States?
Provide an explanation.
Have you ever engaged, or do you plan to engage, solely,
principally, or incidentally, in any activity to violate any law of the
United States relating to espionage or sabotage?

Yes/No

Instructional Text

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Text
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Text

Yes/No

Radio

Yes/No

Text
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Yes/No

Text
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Yes/No

Text
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Yes/No

Text
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821 - Basis of Eligibility

I-821: BASIS OF ELIGIBILITY

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Question

Question

(If Yes to 7.13.a)
7.13.b

Provide an explanation.
Have you ever engaged, or do you plan to engage, solely,
principally, or incidentally, in any activity to violate or evade any
law prohibiting the export from the United States of goods,
technology, or sensitive information?
Provide an explanation.
Have you ever engaged, or do you plan to engage, solely,
principally, or incidentally, in any other unlawful activity in the
United States?
Provide an explanation.
Have you ever engaged, or do you plan to engage, solely,
principally, or incidentally, in 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?
Provide an explanation.
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?

(If Yes to 7.13.b)
7.13.c

(If Yes to 7.13.c)
7.13.d

(If Yes to 7.13.d)
7.14.b

(If Yes to 7.14.b)
7.9.c

Moral character

(If Yes to 7.9.c)
7.12.a
(If Yes to 7.12.a)
7.12.b

(If Yes to 7.12.b)
7.12.e

(If Yes to 7.12.e)
7.18.a
(If Yes to 7.18.a)
7.18.b

(If Yes to 7.18.b)
7.18.c
(If Yes to 7.18.c)
7.19
(If Yes to 7.19)
7.23.c
(If Yes to 7.23.c)
Moral character page 7.27
2
(If Yes to 7.27)

Provide an explanation.
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?
Provide an explanation.
Have you ever trafficked in or are you now trafficking in any
controlled substance?
Provide an explanation.
Are you now or have you ever knowingly assisted, abetted,
conspired, or colluded with others in the unlawful trafficking of
any controlled substance?
Provide an explanation.
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?
Provide an explanation.
Have you ever, within the past 10 years, or are you now engaged in
prostitution or procurement of prostitution?
Provide an explanation.
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?
Provide an explanation.
Have you ever, within the past 10 years, received, in whole or in
part, the proceeds of prostitution?
Provide an explanation.
Have you ever been or do you intend to be involved in any other
commercial vice?
Provide an explanation.
Are you now or have you ever been a drug abuser or
drug addict?
Provide an explanation.
Do you now practice polygamy?
Provide an explanation.

Sub-Question Field Type

Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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Yes/No

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821 - Basis of Eligibility

I-821: BASIS OF ELIGIBILITY

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Paper Form
Question

Question

7.29

Have you ever detained, retained, or withheld the custody of a
Yes/No
child having a lawful claim to U.S. citizenship, outside the United
States, from a U.S. citizen granted custody?
Provide an explanation.
Have you ever committed or conspired to commit human
Yes/No
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?
Provide an explanation.
Yes/No
Have you ever knowingly aided, abetted, assisted, conspired, or
colluded with a human trafficker?
Provide an explanation.
Within the previous five years, have you ever obtained any
Yes/No
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?

Radio

Provide an explanation.

Yes/No

Text
Radio

Yes/No

Text
Radio

(If Yes to 7.29)
7.38.a

(If Yes to 7.38.a)
7.38.d

(If Yes to 7.38.d)
7.38.e

(If Yes to 7.38.e)
7.39.a

(If Yes to 7.39.a)
7.39.b

(If Yes to 7.39.b)

Are you now or have you ever engaged in money laundering as
described in section 1956 or 1957 of Title 18, United States Code?
Provide an explanation.
Are you now or have you ever been a knowing aider, abettor,
assister, conspirator, or colluder with others in money laundering?
Provide an explanation.

Instructional Text

Help Text

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Radio

Text

821 - Basis of Eligibility

I-821: EVIDENCE

Evidence Title
Proof of Temporary Protected
Status

Field Type
Upload

Logic
Notes
If 1.1.b AND 1.2 =
not included in first release
Immigration Judge/Board of
Immigration Appeals
If 1.1.a

Attestations; Birth Certificates; Employment Records; Medical Records; Other
Documents; Rent Receipt; School Records; Utility Bill; W-2

Upload

If 1.1.a

Upload proof of your date of entry into the United States. Examples of documents you may submit include copies of your:
- Passport (cover to cover);
- Form I-94, Arrival-Departure Record; or
- Any documents outlined under Proof of residence on the previous page.

Attestations; Birth Certificates; Employment Records; I-94; Medical Records;
Other Documents; Passport - All Pages, Passport (ID Page); Rent Receipt; School
Records; Utility Bill; W-2

Upload

If 1.1.a

If you were ever arrested, charged, and/or convicted for a criminal offense, you will need to provide court disposition records.
Upload a certified copy of all arrest reports, court dispositions, sentencing documents, and any other relevant documents. You may also include any mitigating evidence concerning the circumstances of your arrests or
convictions that you would like USCIS to consider if you have been arrested or convicted of a crime. If you were placed on probation, you must provide evidence to show that you completed your probationary period.

Court Records; Court Petition/Motion; Court/Custodian Order; Other Supporting
Documents; Photographs; Police/Arrest Records; Sentencing Documents; Written
Statement

Instructional Text
If you are submitting a first-time re-registration with USCIS following an Immigration Judge or Board of Immigration Appeals decision granting your TPS application, upload a copy of the TPS decision order.

Document Type (For evidence uploader document type dropdown)
TPS Decision Order

Proof of identity Proof of Identity and Nationality
and nationality

Upload proof of your identity and nationality. Examples of documents you may submit include copies of your:

Birth Certificate; Government ID; Passport - All Pages; Passport (ID Page)

Proof of
residence

Upload proof of your continuous residence in the United States. Examples of documents you may submit include copies of your:

Proof of Residence

- Passport (cover to cover);
- Birth certificate accompanied by photo identification; or
- Any national identity document from your country of origin that includes your photo and/or fingerprint.

•
Employment records (for example, pay stubs; Form W-2, Wage and Tax Statement; certification of the filing of Federal income tax returns; state verification of the filing of state income tax returns; letters from employers;
or, if you are self-employed, letters from banks and other firms with which you have done business.)
NOTE: In all of these documents, your name and the name of the employer or other interested organization must appear on the form or letter, as well as relevant dates. Letters from employers must be in affidavit form
and the employer must also sign and attest to the affidavit under penalty of perjury.
Such letters must include:
(1) Your address at the time of employment;
(2) Exact periods of employment;
(3) Periods of layoff; and
(4) Duties with the company.
If the employment records are unavailable, submit an affidavit explaining why you cannot obtain these records. Your employer must sign and attest to the affidavit under penalty of perjury.
•
Rent receipts, utility bills (for example, gas, electric and phone), and receipts or letters from companies showing the dates during which you received service.
•
School records (for example, letters, and report cards) from the schools that you or your children have attended in the United States, showing the names of the schools and periods of school attendance.
•
Hospital or medical records concerning treatment or hospitalization of you or your children, showing the name of the medical facility or physician, and the dates of the treatment or hospitalization.
•
Attestations by churches, unions, or other organizations to your residence, identifying you by name. The attestation must be signed by an official (whose title is shown); show inclusive dates of membership; state the
address where you resided during membership periods; include the seal of the organization impressed on the letter or the letterhead of the organization, if the organization has letterhead stationery; establish how the
author knows you; and establish the origin of the information being attested to.
•
Additional documents may include copies of money order receipts for money sent in or out of the country; passport entries; birth certificates of children born in the United States; dated bank transactions;
correspondence between you and another person or organization; U.S. Social Security card; Selective Service card; automobile license receipts, title, vehicle registration; deeds, mortgages, contracts to which you have
been a party; tax receipts; insurance policies; receipts; and letters.
•
Any other relevant documents.

Proof of entry

Proof of Entry

Criminal history Criminal History

If yes to 7.8.a-c; 7.10a-c;
7.11; or 7.15.a-c

You do not need to submit documentation for traffic fines and incidents (unless the traffic fines or incidents were alcohol- or drug-related) that did not involve an actual arrest if the penalty was only a fine of less than
$500 or points on your driver’s license. However, if you were arrested for any traffic offense, provide disposition documentation, so USCIS can properly assess whether your conviction may relate to your TPS eligibility.
If official documents are not available to you, you must establish that the documents are not available to you or your designated representative. If you claim that a record is not available because of a “confidentiality” law
or other reason, please submit:
(1) A copy of your petition or motion to the court or other custodian of the record seeking permission to obtain a copy to submit with your application; and
(2) A copy of the court’s or custodian’s order denying permission, if possible.
If you show that you cannot obtain a copy of the official record, you can submit any secondary evidence that might be
available, such as copies that you or your attorney may have retained.
If you cannot obtain primary or secondary evidence, you must provide at least one written statement. Each written statement must:
(1) Be from a named individual who has personal knowledge to the proceeding;
(2) Explain the source of the individual’s personal knowledge;
(3) Describe the nature of the proceeding, the underlying charges, and the disposition; and (4) Be signed by the individual under oath, affirmation, or penalty of perjury.

821 - Evidence

I-821: ADDITIONAL INFORMATION
Section

Section

Additional
Information

Additional Information

Paper Form Question Question
You may provide additional information for your application

Sub-Question

Field Type Required? Instructional Text

Additional information Textbox

Help Text Notes

If you need to provide any additional information for
any of your answers to the questions in this form, enter
it into the space below. You should include the
questions that you are referencing.
If you do not need to provide any additional
information, you may leave this section blank.

821 - Additional Information

I-821: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and attestations on the paper form. Review and Submit should contain all of the copy relating to reviewing the
application, the preparer/interpreter's certification and signature, the applicant's statements and signature, and paying/submitting the application.
Primary Nav

Review and Submit

Secondary Nav
Review your application

Tertiary Nav

Paper Form

Question
Check your application before you submit

Sub-Question

Field Type

Instructional Text
CTA
We will review your application to check for accuracy and completeness
before you submit it.

Notes
Content specific to digital environment

We encourage you to provide as many responses as you can throughout
the application, to the best of your knowledge. Missing information can
slow down the review process after you submit your application.
You can return to this page to review your application as many times as
you want before you submit it.

Your fee

Your form filing fee is: [$XXX}

Exact fee will be calculated and displayed

Refund Policy: USCIS does not refund fees, regardless of any action we
take on your application, petition or request, or how long USCIS takes to
reach a decision. By continuing this transaction, you acknowledge that
you must submit fees in the exact amount and that you are paying the
fees for a government service.
Alerts and warnings

You have one or more alerts and warnings based on the information you
provided in your application.

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A red alert means you have incomplete or incorrect responses to certain
questions. You cannot submit your application with any alerts.
Your application summary

Review the I-821 form information

Here is a summary of all the information you provided in your
application.

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Make sure you have provided responses for everything that applies to
you before you submit your application. You can edit your responses by
going to each application section using the site navigation.
We also prepared a draft case snapshot with your responses, which you
can download below.
(IF PREPARER) Preparer
statement

Preparer's statement

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant
and with the applicant's consent.

Radio

Your preparer must read the statements below and select the statement
that applies to him or her.
If your preparer is an attorney or accredited representative whose
representation extends beyond preparation of this application, he or she
may be obliged to submit a completed Notice of Entry of Appearance as
Attorney or Accredited Representative (G-28) with your application.

Preparer's certification and signature

I am an attorney or accredited representative and my representation of the applicant in this case does not
extend beyond the preparation of this application.
I am an attorney or accredited representative and my representation of the applicant in this case extends
beyond the preparation of this application.
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.

Radio
Radio
Your preparer must read and agree to the certification below.

As the applicant's preparer, you must sign on paper and provide your signature page to the applicant. Follow
these steps:

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1. Download the Preparer Signature page
2. Print the Preparer Signature page
3. Read and sign the Preparer Signature page
4. Give the signed Preparer Signature page to the applicant
The applicant will need to scan and upload your completed signature page on the next screen.
(IF PREPARER) Preparer
signature
(IF INTERPRETER)
Interpreter certification

Preparer's signature upload
Interpreter's certification and signature

Upload
I certify, under penalty of perjury, that: I am fluent in English and the language provided in the Getting Started
section of this application, 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.

Scan and upload your preparer's completed signature page below.
Your interpreter must read and agree to the certification below.

As the applicant's interpreter, you must sign on paper and provide your signature page to the applicant. Follow
these steps:

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1. Download the Interpreter Signature page
2. Print the Interpreter Signature page
3. Read and sign the Interpreter Signature page
4. Give the signed Interpreter Signature page to the applicant
The applicant will need to scan and upload your completed signature page on the next screen.
(IF INTERPRETER)
Interpreter signature
Your statement

Interpreter's signature upload
Applicant's statement
Applicant's statement regarding the preparer
Applicant's statement regarding the interpreter

Upload
I can read and understand English, and have read and understand every question and instruction on this
Checkbox
application, as well as my answer to every question.
At my request, the preparer named in the Getting Started section of this application prepared this application
Checkbox
for me based only upon the information I provided or authorized.
The interpreter named in the Getting Started section of this application read to me every question and
Checkbox
instruction on this application and my answer to every question in the language I specified in the Getting Started
section, a language in which I am fluent, and I understood everything.

Scan and upload your interpreter's completed signature page below.
You must read and agree to the statement below.
You must read and agree to the statement below.
You must read and agree to the statement below.

821 - Review & Submit

I-821: REVIEW AND SUBMIT

Secondary Nav
(If "Your Statement" is
complete) Your signature

Tertiary Nav

Paper Form

Question

Sub-Question

Applicant's Certification

Field Type

Instructional Text

CTA

Notes

You must read and agree to the certification below. If you knowingly and
willfully falsify or conceal a material fact or submit a false document
with your application, we can deny your application and may deny any
other immigration benefit. You may also face criminal prosecution and
penalties provided by the law.

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

(No nav)

(If 1.3a selected) Finish and continue to I-765

I have read and agree to the applicant's statement

Finish the I-821 and continue to the I-765
By finishing this form, your Form I-821 will be locked and no further changes can be made. Please make sure
that the information on your Form I-821 is complete and accurate before continuing. If you need to make any
edits after finishing, you will need to create a new Form I-821.

Checkbox

You must provide your digital signature below by typing your full legal
name. We may deny your application if you do not completely fill out
this application or fail to submit required documents. We will record the
date of your signature with your application.

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Required field

Submit
Finish and
continue

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Next, you will continue to Form I-765. Once you complete Form I-765, you can pay for and submit both forms at
the same time.

821 - Review & Submit

I-765 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Heading
I-765, Application for Employment
Authorization

Sub-Heading

Body Text
Certain foreign nationals who are in the United States may file Form I-765, Application for Employment Authorization, to request employment authorization and an Employment
Authorization Document (EAD). Other foreign nationals whose immigration status authorizes them to work in the United States without restrictions may also use Form I-765 to apply for
an EAD that shows such authorization.

Link
CTA
https://ww
w.uscis.gov/
i-765

Notes
Form I-765 instructions, "What Is the Purpose
of Form I-765" - page 1

Foreign nationals may also apply for a Social Security number and card on Form I-765.
If you are a lawful permanent resident, a conditional permanent resident, or a nonimmigrant only authorized for employment with a specific employer under 8 CFR 274a.12(b), do not
use Form I-765.
Learn more about employment authorization.
Before You Start Your Application

Eligibility

You may apply online if your eligibility category is:
-
(c)(3)(A) - F-1 student, pre-completion OPT;
-
(c)(3)(B) - F-1 student, post-completion OPT;
-
(c)(3)(C) - F-1 student, 24-month extension for STEM students (students holding a degree in science, technology, engineering, or mathematics);
-
(a)(12) - Temporary Protected Status (You are submitting an initial Form I-821 or you have an approved Form I-821.); or
-
(c)(19) - Temporary Protected Status (You have a pending Form I-821.)

https://ww
w.uscis.gov/
i-765

Note: You may submit Form I-765 online as an (a)(12) or (c)(19) applicant only if you are:
-
A national of Burma, Haiti, Syria or Venezuela, or a person without nationality who last habitually resided in one of these four countries;
-
Filing an initial application for TPS; and
-
Applying for an initial request to accept employment or renewing permission to accept employment.
All other applicants must submit a paper Form I-765.
F1 Students Seeking Optional Practical Training (OPT)
(c)(3)(A) eligibility category: Submit Form I-765 up to 90 days before being enrolled as an F-1 foreign student for one full academic year at an educational institution approved by U.S.
Immigration and Customs Enforcement (ICE) and Student and Exchange Visitor Program (SEVP). Your period of employment will not start before you have completed one full academic
year. If you completed the one-year requirement while in another valid nonimmigrant status and you are now in valid F-1 status, you are still eligible to apply for OPT.

Form I-765 instructions, "Who May File Form I765"- pages 6-8

(c)(3)(B) eligibility category: Submit Form I-765 up to 90 days before, but no later than 60 days after your program end date. You must submit your application within 30 days of the date
that your designated school official (DSO) enters the recommendation for OPT into your Student and Exchange Visitor Information System (SEVIS) record. If you fail to do so, we will deny
your OPT request.
(c)(3)(C) eligibility category: Submit Form I-765 application up to 90 days before your current OPT expires, but you must submit within 60 days of the DSO's approval of STEM OPT.
Note: If you are an F-1 student filing for initial or extension of OPT, your OPT and your employment authorization will be automatically terminated if you change educational program
levels or transfer to another school. Working in the United States without authorization may result in your removal from the United States or denial of re-entry. Consult your DSO for
additional details.
Temporary Protected Status
(a)(12) and (c)(19) eligibility categories: Submit your application with your Form I-821 application or with evidence that we accepted or approved your initial Form I-821. Include evidence
of your nationality and identity as required by the Form I-821 Instructions. If an EOIR Immigration Judge (EOIR IJ) or the Board of Immigration Appeals (BIA) granted TPS and you are
requesting your first EAD, you must submit a copy of the order that granted TPS with your Form I-765 (such as a copy of your Form I-821 that the EOIR IJ or BIA approved). You must also
follow the instructions for filing your application as described in the most recent TPS Federal Register notice regarding a TPS designation, re-designation, or extension for your country.
Note: You may submit this form with Form I-821 online if you are applying under the (a)(12) eligibility category and applying for an initial request to accept employment.

Fee

Fee: $410. If you are requesting an EAD as an initial TPS applicant, you must pay the Form I-765 filing fee, unless you are younger than 14 or older than 65.
Note: If you are submitting this form with Form I-821, your total application fee will reflect the fees for Form I-821, Form I-765, and Biometric Services (if required). You will pay for all
three at the end of this form.

Form I-765 instructions, "What Is the Filing
Fee"- page 6

Refund policy:
USCIS does not refund fees, regardless of any action we take on your application, petition or request, or how long USCIS takes to reach a decision. By continuing this transaction, you
acknowledge that you must submit fees in the exact amount and that you are paying the fees for a government service.

Documents you may need

Please refer to the instructions for the form(s) you are filing for additional information or you may call the USCIS Contact Center at 800-375-5283. For TTY (deaf or hard of hearing) 800767-1833.
Most applicants must upload:
- A copy of your Form I-94, Nonimmigrant Arrival-Departure Record (front and back), a printout of your electronic Form I-94 from www.cbp.gov/i94, passport, or other travel document.
- A copy of your last EAD (front and back). If you were not previously issued an EAD, you must submit a copy of a government-issued identity document (such as a passport) showing your
picture, name, and date of birth;
a birth certificate with photo ID; a visa issued by a foreign consulate; or a national ID document with photo
and/or fingerprint. The identity document photocopy must clearly show your facial features and contain your
biographical information.
- A color passport-style photograph of yourself taken recently.
We will automatically inform you which documents and additional evidence you may need to provide as you fill out your application. These recommendations for additional information
will be based on the information you provide in the application, such as your personal history and circumstances.

Form I-765 instructions, "Required
Documentation" - pages 25-26

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Any document containing foreign language submitted to USCIS must be accompanied by a full English language translation that the translator has certified as complete and accurate, and
by the translator's certification that he or she is competent to translate from the foreign language into English.

765- Application Overview

I-765 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Heading

After You Submit Your Application

Completing Your Form Online

Link

CTA

Notes

Sub-Heading

Body Text

Biometric services appointment

USCIS may require that you appear for an interview or provide biometrics (fingerprints, photograph, and/or signature) at any time to verify your identity, obtain additional information,
and conduct background and security checks, including a check of criminal history records maintained by the Federal Bureau of Investigation (FBI), before making a decision on your
application or petition. After USCIS receives your application and ensures it is complete, we will inform you in writing if you need to attend a biometric services appointment. If an
appointment is necessary, the notice will provide you the location of your local or designated USCIS Application Support
Center (ASC) and the date and time of your appointment.

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Track your case online

After you submit your form, you can track its status through your USCIS account. Sign in to your account often to check your case status and read any important messages from USCIS.

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Respond to requests for information

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Receive your decision

If we need more information from you, we will send you a Request for Evidence (RFE) or Request for Information (RFI). You can respond to our request and upload your documents
through your USCIS account.
The decision on Form I-765 involves a determination of whether you have established eligibility for the immigration benefit you are seeking. USCIS will notify you of the decision in
writing. If your application is approved, we will either mail your EAD to you or we may require you to visit your local USCIS office to pick it up. If USCIS cannot approve your application,
you will receive a written notice explaining the basis of your denial.

Filing online

Submitting your application online is the same as mailing in a completed paper form. They both gather the same information.

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Complete the Getting Started section first

You should answer all questions in the Getting Started section first so we can best customize the rest of your online form experience.

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Form I-765 instructions, "Processing
Information" - page 29

Provide as many responses as you can
You should provide as many responses as you can. Incomplete fields or sections and missing information can slow down the process after you submit your form.
We will automatically save your responses We will automatically save your information when you select next to go to a new page or navigate to another section of the form. We will save your information for 30 days from today,
or from the last time you worked on the form.
How to continue filling out your form
After you start your form, you can sign in to your account to continue where you left off.
DHS Privacy Notice
AUTHORITIES: The information requested on this application, and the associated evidence, is collected under the Immigration and Nationality Act, 8 U.S.C. section 1324a, 8 CFR 274a.12,
and 8 CFR 274a.13.
PURPOSE: The primary purpose for providing the requested information on this application is to determine eligibility for certain aliens who are temporarily in the United States
requesting an Employment Authorization Document. DHS uses the information you provide to grant or deny the benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your Social Security number, and any requested evidence may
delay a final decision or result in a rejection or denial of your application.

Paperwork Reduction Act

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Form I-765 instructions, "DHS Privacy Notice" page 30
Form I-765 instructions, "DHS Privacy Notice" page 30
Form I-765 instructions, "DHS Privacy Notice" page 30

ROUTINE USES: DHS may, where allowable under relevant confidentiality provisions, share the information
you provide on this application and any additional requested evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows
approved routine uses, as described in the associated published system of records notices [DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System; DHS/USCIS-007
Benefit Information System; DHS/USCIS-010 Asylum Information and Pre-Screening; and, DHS/USCIS-017 Refugee Case Processing and Security Screening Information System; DHS/USCIS018 Immigration Biometric and Background Check] and the published privacy impact assessments [DHS/USCIS/PIA-016(a) Computer Linked Application Information Management System
and Associated Systems; DHS/USCIS/PIA-027 Asylum Division; DHS/USCIS/PIA-056 USCIS Electronic Immigration System; and DHS/USCIS/PIA-068 Refugee Case Processing and Security
Vetting], which can be found at www.dhs.gov/privacy [https://www.dhs.gov/topic/privacy]. DHS may also share this information as appropriate for law enforcement purposes or in the
interest of national security.

Form I-765 instructions, "DHS Privacy Notice" page 31

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid Office of
Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 4 hours per response, including the time for reviewing
instructions, gathering the required documentation and information, completing the application, preparing statements, attaching necessary documentation, and submitting the
application. The collection of biometrics is estimated to require 1 hour and 10 minutes. The public reporting burden for the collection of information for Form I-765WS is estimated at 30
minutes per response, including the time for reviewing instructions, gathering the required documentation and information, completing the application, preparing statements, attaching
necessary documentation, and submitting the application. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to:

Form I-765 instructions, "Paperwork Reduction
Act" - page 31

U.S. Citizenship and Immigration Services
Office of Policy and Strategy, Regulatory Coordination Division
5900 Capital Gateway Drive, Mail Stop #2140
Camp Springs, MD 20588-0009
Do not mail your completed Form I-765 to this address.
OMB No. 1615-0040
Expires: 07/31/2022
Security reminder

If you do not work on your application for more than 30 days, we will delete your data in order to prevent storing personal information indefinitely.

Start

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765- Application Overview

I-765: GETTING STARTED

The Getting Started step is the first part of the form that the applicant will complete. Questions relating to the applicant's basis for eligibility (if applicable) and questions about the applicant's preparer/interpreter (if any) should be grouped in the Getting Started step of the form and should be
Primary Nav Secondary Tertiary Nav Paper Form Question
Notes
Help Text
Question
Sub-Question
Field Type Instructional Text
Nav
Getting
Started

Basis of
eligibility

2.27

What is your eligibility category?

2.28.a

[If you entered the eligibility category (c)(3)C]
What is your degree?
[If you entered the eligibility category (c)(3)C]
What is your employer's name as listed in E-Verify?
[If you entered the eligibility category (c)(3)C]
What is your employer's E-Verify company identification number or a
valid E-Verify client company identification number?
[If you entered the eligibility category (c)(8)] Are you a Salvadoran or
Guatemalan national eligible for benefits under the ABC settlement
agreement?

2.28.b
2.28.c

3.6

Reason for
applying

Dropdown

Required field. (only (a)(12)
supported for concurrent filing)

Text
Text
Text

Yes/No

Radio

What is your reason for applying?

a. Initial permission to accept employment.

Radio
Radio

If concurrently filed with I-821,
selection does not display

Radio

Have you previously filed Form I-765?
Is someone assisting you with completing this application?

b. Replacement of lost, stolen, or damaged
employment authorization document, or
correction of my employment authorization
document NOT DUE to U.S. Citizenship and
Immigration Services (USCIS) error.
c. Renewal of permission to accept
employment.
Yes/No
Yes/No

If concurrently filed with I-821,
selection does not display

(IF YES) Is a preparer assisting you with completing this application?

Yes/No

Radio

A preparer is anyone who completes or
helps you complete all or part of your
application using information and
answers that you provide.

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environment

(IF YES) Is an interpreter assisting you with completing this application? Yes/No

Radio

An interpreter is anyone who translates
or helps you translate all or part of your
application using information and
answers that you provide.

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environment

5.1.b

What is your preparer's full name?

Given name (first name)

Text

5.1.a
5.2

What is your preparer's business or organization name?

Family name (last name)

Text
Text
Checkbox

5.3.a.-5.3.h.

What is your preparer's mailing address?

5.4
5.5

What is your preparer's contact information?

1.1.a
1.1.b

1.1.c
2.12
Preparer
and
interpreter
information

(IF YES TO
PREPARER
QUESTION)
Preparer
information

Eligibility Category

5.6

My preparer is not part of a business or
organization.
Country
Address line 1
Address line 2
City or town
State/Province

Question will not be included in
initial release because c(8)
category is not currently
supported
Required field

Radio
Radio

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environment

Dropdown
Text
Street number and name
Text
Apartment, suite, unit, or floor
Text
Dropdown/T
ext
Text
Text
Text
Checkbox

ZIP code/Postal code
Daytime phone number
Mobile telephone number
My preparer does not have a mobile
telephone number
Email address
Text
My preparer does not have an email address. Checkbox

765- Getting Started

I-765: GETTING STARTED

4.1.b

What is your interpreter's full name?

4.1.a
4.2

What is your interpreter's business or organization name?

4.3

What is your interpreter's mailing address?

4.4
4.5

What is your interpreter's contact information?

4.6

What language is your interpreter using to interpret this application for
you?

Given name (first name)

Text

Family name (last name)

Text
Text
Checkbox

My interpreter is not part of a business or
organization.
Country
Address line 1
Address line 2
City or town
State/Province
ZIP code/Postal code
Daytime telephone number
Mobile telephone number
My interpreter does not have a mobile
telephone number
Email address
My interpreter does not have an email
address.

Dropdown
Text
Street number and name
Text
Apartment, suite, unit, or floor
Text
Dropdown/T
ext
Text
Text
Text
Checkbox
Text
Checkbox
Text

765- Getting Started

I-765: ABOUT YOU

The About You step is the second part of the paper form that the applicant will complete. Questions relating to the applicant's personal information should be grouped in the About you step of the form and should be organized by the appropriate section. This step and
section structure will inform the navigation and sub-navigation for the form. Personal information questions include questions about the applicant's name, contact information, immigration information, demographics, school and employment, military service, requests
for accommodations, etc.
Primary Nav Secondary Nav Tertiary Nav
About You

Your name

Your contact
information

Describe
yourself
When and
where you
were born

Your
immigration
information

Paper Form Question
Question
2.1.b
What is your current legal name?

Sub-Question

2.1.c
2.1a

Middle name
Family name (last name)
Yes/No

2.2b
2.2c
2.2a
3.3

Have you used any other names
since birth?
(If yes)

How may we contact you?

Instructional Text

Given name (first name)
Middle name
Family name (last name)
Daytime telephone number
Mobile telephone number (if any)

3.5
2.5.a

This is the same as my daytime
telephone number.
Email address
In care of name (if any)

Help Text

Other names used may include
nicknames, aliases, and maiden names.
Provide the other names you have used.

Text
Text

We will use your current mailing address
to contact you throughout the
application process. We may not be able
to contact you if you do not provide a
complete and valid address. Please
provide a U.S. address only.
Street number and name
Required field
Apartment, suite, unit, or floor
Required field
Required field
Required field

Address line 1
Address line 2
City or town
State
ZIP code
Is your current mailing address the Yes/No
same as your physical address?

Text
Text
Text
Dropdown
Text
Radio

2.7.a

(If no) Where in the United States
do you live?

Address line 1

Text

Street number and name

Address line 2
City or town
State
ZIP code
Male/Female

Text
Text
Dropdown
Text
Radio

Apartment, suite, unit, or floor

Single, Married, Divorced, Widowed

Radio
Text

What is your gender?

2.12
2.19a

What is your marital status?
What is your city, town, or village
of birth?

2.19b

What is your state or province of
birth?
What is your country of birth?
What is your date of birth?
(mm/dd/yyyy)
What is your country of citizenship
or nationality?

2.19c
2.20
2.18

Required field

Text (9
digits)
Text (9
digits)
Checkbox

2.5.b
2.5.c
2.5.d
2.5.e
2.5.f
2.6

2.7.b
2.7.c
2.7.d
2.7.e
2.10

Notes

Your current legal name is the name on
your birth certificate, unless it changed
after birth by a legal action such as
marriage or court order. Do not provide
any nicknames here.

Given name (first name)

3.4

What is your current U.S. mailing
address?

Field Type

Text
Dropdown
Date
Dropdown

List all countries where you are
currently a citizen or national.

Required field
User will be able to input
multiple countries (at least
two based on paper form). It
will be a table or list.

765-About You

I-765: ABOUT YOU

The About You step is the second part of the paper form that the applicant will complete. Questions relating to the applicant's personal information should be grouped in the About you step of the form and should be organized by the appropriate section. This step and
section structure will inform the navigation and sub-navigation for the form. Personal information questions include questions about the applicant's name, contact information, immigration information, demographics, school and employment, military service, requests
for accommodations, etc.
Primary Nav Secondary Nav Tertiary Nav

Paper Form Question
Question
2.21.a

2.22
2.23
2.24
2.21.b

2.21c
2.21.e
2.21.d
2.25
2.26

Other
information

2.8

2.9

2.13a

2.13b
2.14
2.15

2.16b

Sub-Question

What is your Form I-94 ArrivalDeparture Record Number (if any)?
When did you last arrive in the
United States?

What is the passport number of
your most recently issued
passport?
What is your travel document
number (if any)?
What is the expiration date of your
passport or travel document?
What country issued your passport
or travel document?
What is your current immigration
status or category?
What is your Student and Exchange
Visitor Information System (SEVIS)
Number (if any) ?
What is your A-Number?

11 character
restricted
text

Date of arrival
Place of arrival
Status at last arrival

Date
Dropdown
Dropdown
Text

Instructional Text

List your arrival date, place of
arrival, and status at arrival.

Help Text

Notes

mm/dd/yy

Text
(mm/dd/yyyy)

Date

Country

Dropdown
Dropdown

N-

Text

A-

Text (9
digits)
Checkbox

I do not have or know my ANumber.
What is your USCIS Online Account
Number?

I do not have or know my USCIS
Online Account Number.
Has the Social Security
Administration (SSA) ever officially
issued a Social Security card to
you?
(If yes to 2.13a) What is your Social
Security number (if known)?
Do you want the SSA to issue you a
Social Security card?
(If yes to 2.14) Consent for
Disclosure: I authorize disclosure of
information from this application
to the SSA as required for the
purpose of assigning me an SSN
and issuing me a Social Security
card.
(If yes to 2.15) What is your father's
birth name?

Field Type

Text (12
digits)

Use the "Additional Information"
section to include all previously
used SEVIS numbers.

Providing your unique USCIS Online
Account Number (OAN) helps us
manage your account. You may
already have an OAN if you
previously filed certain paper forms
and received an Account Access
Notice in the mail. You can find the
OAN at the top of the notice; it is
not the same as an A-Number.

The phrase "certain paper forms" would
have a tooltip that would list the forms: "I90, I-130, I-485, I-821, I-821D, N-336, N400, N-565, N-600, N-600K"

Checkbox
Yes/No

Radio

Yes/No

Text (9
digits)
Radio

Yes/No

Radio

Given name (first name)

Text

765-About You

I-765: ABOUT YOU

The About You step is the second part of the paper form that the applicant will complete. Questions relating to the applicant's personal information should be grouped in the About you step of the form and should be organized by the appropriate section. This step and
section structure will inform the navigation and sub-navigation for the form. Personal information questions include questions about the applicant's name, contact information, immigration information, demographics, school and employment, military service, requests
for accommodations, etc.
Primary Nav Secondary Nav Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

2.16a
2.17b

Family name (last name)
Given name (first name)

Text
Text

Family name (last name)

Text

2.17a

(If yes to 2.15) What is your
mother's birth name?

Instructional Text

Help Text

Notes

765-About You

I-765: EVIDENCE

The Evidence step is for forms that require the applicant to submit evidence to USCIS. As the applicant completes the form, the form's logic will dictate which pieces of evidence a particular applicant should
Primary Nav
Secondary Nav
Paper Form
Logic
Instructional Text
Field Type Links
Evidence Title
2 x 2 Photo of you
Form I-765
2 x 2 Photo of You
Upload a recent color photograph of yourself that measures 2 inches by 2 Upload
https://trav
Evidence
instructions,
inches, with your face measuring 1 inch to 1 3/8 inch from your chin to
el.state.gov/
"Required
the top of your head. Your eyes should be between 1 1/8 inch and 1 3/8
content/trav
Documentation" inch from the bottom of the photo.
el/en/uspages 25-26
visas/visaMake sure your whole face is visible, you are facing the camera directly,
informationand the background is white or off-white. Your head must be bare, unless
resources/p
contrary to your religious beliefs.
hotos.html

Form I-94

Form I-765
instructions,
"Required
Documentation" page 25

I-94, Arrival and Departure
Record

If you need help understanding the photo requirements or want to
resize, rotate, or crop your photo, you can use to the Department of
State's photo composition tools. Please note that we cannot approve
your application without your photo.
Upload a copy of one of the following:
- Your Form I-94, Arrival-Departure Record (front and back);
- A printout of your electronic Form I-94 ; or
- Your passport or other travel document.

Upload

If you were admitted to the United States by CBP at an airport or seaport
after April 30, 2013, CBP may have issued you an electronic Form I-94
instead of a paper Form I-94. You may visit the CBP website to obtain a
paper version of an electronic Form I-94. CBP does not charge a fee for
this service. Some travelers admitted to the United States at a land
border, airport, or seaport, after April 30, 2013, with a passport or travel
document, who were issued a paper Form I-94 by CBP, may also be able
to obtain a replacement Form I-94 from the CBP website without charge.

Notes

https://ww
w.cbp.gov/t
ravel/intern
ationalvisitors/i-94
www.uscis.g
ov/i-102

If your Form I-94 cannot be obtained from the CBP website, it may be
obtained by filing Form I-102, Application for Replacement/Initial
Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a
fee for this service.

Employment Authorization Form I-765
Document
instructions,
"Required
Documentation" page 25

Proof of enrollment

Form I-765
instructions, "Who
May File Form I765"- page 7

Previously authorized CPT
or OPT

Form I-765
instructions, "Who
May File Form I765"- pages 7-8

Employment Authorization Upload a copy of your last Employment Authorization document (EAD)
Upload
Document or Government ID (front and back). If you were not previously issued an EAD, you must
upload a copy of a government-issued identity document (such as a
passport) showing your picture, name, and date of birth; a birth
certificate with photo ID; a visa issued by a foreign consulate; or a
national ID document with photo and/or fingerprint. The identity
document photocopy must clearly show your facial features and contain
your biographical information.
Proof of Enrollment
Upload evidence of having been lawfully enrolled on a full-time basis for
one full academic year at a college, university, conservatory, or seminary
approved by the U.S. Immigration and Customs Enforcement (ICE)
Student and Exchange Visitor Program (SEVP) for attendance by F-1
foreign students.
Previously Authorized CPT or Upload evidence of any previously authorized CPT or OPT and the
OPT
academic level at which it was authorized.

If eligibility category is (c)(3)(A) If eligibility category is
(c)(3)(A)

If eligibility category is (c)(3)(A) If eligibility category is
or (c)(3)(B
(c)(3)(A) or (c)(3)(B

765-Evidence

I-765: EVIDENCE

Form I-765
instructions, "Who
May File Form I765"- pages 7-8

I-20, Certificate of Eligibility Upload a copy of the Form I-20, Certificate of Eligibility for Nonimmigrant Upload
for Nonimmigrant Student Student Status endorsed by the Designated School Official (DSO). For the
Status
(c)(3)(B) eligibility category, your DSO must have entered the
recommendation for OPT into your SEVIS record within 30 days of you
submitting Form I-765. If you fail to do so, we will deny your OPT
request. For the (c)(3)(C) eligibility category, the Form I-20 must have
been endorsed by the DSO within 60 days of submitting Form I-765.

College degree

Form I-765
instructions, "Who
May File Form I765"- page 8

College Degree

Institution accreditation

Form I-765
instructions, "Who
May File Form I765"- page 8

Institution Accreditation

Proof of TPS

Form I-765
instructions, "Who
May File Form I765" page 6

Form I-821

Form I-765
instructions, "Who
May File Form I765" page 6
Form I-765
instructions, "Who
May File Form I765" page 6

Replacement TPS EAD

Form I-765
instructions, "Who
May File Form I765" page 7

Proof of identity and
nationality

Upload evidence that the degree that is the basis for the STEM OPT
extension is in one of the degree programs currently listed on the STEM
Designated Degree Program List or a copy of your prior STEM degree.

Upload

Upload evidence that the institution that granted your STEM degree is
Upload
currently accredited by the U.S. Department of Education and certified by
the Student Exchange and Visitor Program (SEVP), if this STEM OPT
extension is based on a previously earned STEM degree.
Proof of Temporary
If an EOIR Immigration Judge (EOIR IJ) or the Board of Immigration
Protected Status Granted by Appeals (BIA) granted TPS, and you are requesting your first EAD or are reEOIR Immigration Judge or registering for the first time, upload a copy of the EOIR IJ or BIA order
Board of Immigration
that granted TPS (such as a copy of your Form I-821 that the EOIR IJ or
Appeals
BIA approved).
Upload proof of your identity and nationality. Examples of documents
you may submit include copies of your:

Proof of identity and
nationality
I-821, Application for
Temporary Protect Status

Replacement for Temporary
Protected Status
Employment Authorization
Document

Logic

Notes

If eligibility category is (c)(3)(A) If eligibility category is
or (c)(3)(B or (c)(3)(C)
(c)(3)(A) or (c)(3)(B or
(c)(3)(C)

https://stud If eligibility category is (c)(3)(C) If eligibility category is
yinthestates
(c)(3)(C)
.dhs.gov/ste
m-opthub/eligiblecip-codesfor-the-stemoptextension
If eligibility category is (c)(3)(C) If eligibility category is
(c)(3)(C)

If (a)(12)

(If concurrently filing, do
not show)

If (a)(12)

- Passport (cover to cover);
- Birth certificate accompanied by photo identification; or
- Any national identity document from your country of origin that
includes your photo and/or fingerprint.
If you previously filed Form I-821, upload evidence that we accepted or
approved your initial Form I-821.

If (a)(12) or (c)(19)

If your non-expired TPS EAD is lost, stolen, or damaged, upload a copy of
your approval notice for TPS (if you have been approved) or a copy of
your previous Form I-797 Notice for Form I-821 if your TPS application is
still pending.

If (a)(12) or (c)(19) AND 1.1b

(c)(19) not supported for
concurrent filing. (If
concurrently filing, do not
show)
If (a)(12) or (c)(19) AND
1.1b (c19 not supported for
concurrent filing) (If
concurrently filing, do not
show)

765-Evidence

I-765: ADDITIONAL INFORMATION
Section
Additional
Information

Section
Paper Form Question Question
Additional Information
You may provide additional information for your application

Sub-Question
Field Type Required? Instructional Text
Additional information Textbox No
If you need to provide any additional information for
any of your answers to the questions in this form,
enter it into the space below. You should include the
questions that you are referencing.

Help Text

Notes

If you do not need to provide any additional
information, you may leave this section blank.

765 - Additional Information

I-765: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and
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Review and Submit

Content specific to digital environment

Primary Nav

Review your
application

Check your application before you
submit

We will review your application to check for accuracy
and completeness before you submit it.
We encourage you to provide as many responses as
you can throughout the application, to the best of
your knowledge. Missing information can slow down
the review process after you submit your application.
You can return to this page to review your application
as many times as you want before you submit it.

Your fee

Your form filing fee is: [$XXX}
Refund Policy: USCIS does not refund fees, regardless
of any action we take on your application, petition or
request, or how long USCIS takes to reach a decision.
By continuing this transaction, you acknowledge that
you must submit fees in the exact amount and that
you are paying the fees for a government service.

Alerts and warnings

You have one or more alerts and warnings based on
the information you provided in your application.

Exact fee will be calculated and
displayed

Content specific to digital environment

A red alert means you have incomplete or incorrect
responses to certain questions. You cannot submit
your application with any alerts.

Your application
summary

Review the I-765 form information

Here is a summary of all the information you provided Next
in your application.

Content specific to digital environment

Make sure you have provided responses for
everything that applies to you before you submit your
application. You can edit your responses by going to
each application section using the site navigation.
We also prepared a draft case snapshot with your
responses, which you can download below.

(IF PREPARER)
Preparer
statement

5.7a

Preparer's statement

I am not an attorney or accredited representative but have prepared this application on
behalf of the applicant and with the applicant's consent.

Radio

Your preparer must read the statements below and
select the statement that applies to him or her.
If your preparer is an attorney or accredited
representative whose representation extends beyond
preparation of this application, he or she may be
obliged to submit a completed Notice of Entry of
Appearance as Attorney or Accredited Representative
(G-28) with your application.

5.7b

I am an attorney or accredited representative and my representation of the applicant in
this case does not extend beyond the preparation of this application.

5.7b
5.8a

Preparer's certification and
signature

Radio

I am an attorney or accredited representative and my representation of the applicant in
Radio
this case extends beyond the preparation of this application.
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 Declaration and 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.

Your preparer must read and agree to the
certification below.

765- Review and Submit

I-765: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and
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Primary Nav

As the applicant's preparer, you must sign on paper and provide your signature page to the
applicant. Follow these steps:

Notes
Content specific to digital environment

1. Download the Preparer Signature page
2. Print the Preparer Signature page
3. Read and sign the Preparer Signature page
4. Give the signed Preparer Signature page to the applicant
The applicant will need to scan and upload your completed signature page on the next
screen.
(IF PREPARER)
Preparer
signature
(IF INTERPRETER)
Interpreter
certification

Preparer's signature upload

4.7a

Interpreter's certification and
signature

Upload

I certify, under penalty of perjury, that: I am fluent in English and the language provided in
the Getting Started section of this application, 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 Declaration
and Certification, and has verified the accuracy of every answer.

Scan and upload your preparer's completed signature
page below.
Your interpreter must read and agree to the
certification below.

As the applicant's interpreter, you must sign on paper and provide your signature page to
the applicant. Follow these steps:

Content specific to digital environment

1. Download the Interpreter Signature page
2. Print the Interpreter Signature page
3. Read and sign the Interpreter Signature page
4. Give the signed Interpreter Signature page to the applicant
The applicant will need to scan and upload your completed signature page on the next
screen.
(IF INTERPRETER)
Interpreter
signature
Your statement

(If "Your
Statement" is
complete) Your
signature

Interpreter's signature upload

Upload

Scan and upload your interpreter's completed
signature page below.

3.1a

Applicant's statement

I can read and understand English, and have read and understand every question and
instruction on this application, as well as my answer to every question.

Checkbox

You must read and agree to the statement below.

3.2

Applicant's statement regarding
the preparer

At my request, the preparer named in the Getting Started section of this application
Checkbox
prepared this application for me based only upon the information I provided or authorized.

You must read and agree to the statement below.

3.1b

Applicant's statement regarding
the interpreter

The interpreter named in the Getting Started section of this application read to me every
question and instruction on this application and my answer to every question in the
language I specified in the Getting Started section, a language in which I am fluent, and I
understood everything.

You must read and agree to the statement below.

Form I-765, Applicant's Declaration and
"Applicant's Certification
Declaration
and
Certification
" - pages 4-5

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 and
all of my records that USCIS may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore 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 law.

Checkbox

You must read and agree to the certification below. If
you knowingly and willfully falsify or conceal a
material fact or submit a false document with your
application, we can deny your application and may
deny any other immigration benefit. You may also
face criminal prosecution and penalties provided by
the law.

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, if I am required
to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and understood all of the information contained in, and submitted with, my
application; and
2) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury, that all of the information in my application and any
document submitted with it were provided or authorized by me, that I reviewed and
understand all of the information contained in, and submitted with, my application and
that all of this information is complete, true, and correct.

765- Review and Submit

I-765: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and
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I have read and agree to the applicant's statement
3.7a

Applicant's signature

Checkbox

Content specific to digital environment
You must provide your digital signature below by
typing your full legal name. We may deny your
application if you do not completely fill out this
application or fail to submit required documents. We
will record the date of your signature with your
application.

(If concurrently
filed with I-821)
Finish and
continue to pay
and submit

Finish and continue to pay and
submit

(If Representative
completing form
on behalf of
client) Finish and
continue to G-28

Finish the Form I-765 and continue By finishing this form, your Form I-765 will be locked and no further changes can be
to the G-28
made. Please make sure that the information on your Form I-765 is complete and accurate
before continuing. If you need to make any edits after finishing, you will need to create
both a new Form I-821 and a new Form I-765.

Notes

Required field

By finishing this form, your Form I-765 will be locked and no further changes can be
made. Please make sure that the information on your Form I-765 is complete and accurate
before continuing. If you need to make any edits after finishing, you will need to create
both a new Form I-821 and a new Form I-765.
Next, you will continue to the pay and submit page where you can pay for and submit
both your Form I-821 and Form I-765 at the same time.

We will prepare a draft Form I-821 and Form I-765 for your client to review and sign. If
your client does not approve the information provided in the Form I-821 or Form I-765,
you will need to edit the information in the form, and resubmit it for your client's review.
Next, you will continue to the G-28. When you submit the G-28, we will give you a
passcode for your client to add you as his or her representative in his or her USCSIS online
account. Once you are added, your client will have access to review the draft Form I-821,
the draft Form I-765, and the draft G-28.

(No nav)

Pay for and submit your
applications

The final step to submit your Form I-821, Application for Temporary Protected Status (TPS)
and your Form I-765, Application for Employment Authorization is to pay the required fee.
Form I-821: [$XXX]
Form I-765: [$XXX]
Biometrics: [$XXX]
Your total application fee is: [XXX]
Refund policy: By continuing this transaction, you agree that you are paying for a
government service and that the filing fee, biometric services fee and all related financial
transactions are final and not refundable, regardless of any action USCIS takes on an
application, petition or request, or how long USCIS takes to reach a decision. You must
submit all fees in the exact amounts.
We will send you to Pay.gov — our safe, secure payment website — to pay your fees and
submit your application online.

Pay and
submit

Content specific to digital environment

Here are the steps in the payment and submission process:
1. Provide your billing information on Pay.gov
2. Provide your credit card or U.S. bank account information
3. Submit your payment
When you have paid your fee, your application will be submitted.
Pay.gov will redirect you to a uscis.gov confirmation screen, which will include your receipt
number. Please keep a copy of your receipt number for your records. You can track the
status of your application through your USCIS online account.

( Successful
submission) (No
nav)

We will contact you if we have any questions or need additional information. You can track
You have successfully submitted
the status of your application through your USCIS online account.
both your Application for
Temporary Protected Status (I821) and Application for
Employment Authorization (1-765)

Go to my
cases

765- Review and Submit

I-765: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and
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( Unsuccessful
submission) (No
nav)

You did not submit your
Application for Temporary
Protected Status (I-821) and
Application for Employment
Authorization (1-765)

Notes

Your payment failed or was canceled before it could be processed on Pay.gov.
You can try again now to sign and submit your application or save your application and
exit. We will save your application for 30 days from when you started it.

Sign and
submit

765- Review and Submit

I-821: Alerts

Number

Section

Type

Logic

Message

Notes

h2. Only certain applicants may apply online

Application Overview
and Getting Started,
Reason for Applying

Blue alert

Always displays

Getting Started, Reason
for Applying
Blue alert

If yes to 1.3.a

Review and Submit

If user has not answered
required field

Red alert

You may submit this form online only if you are an eligible
national or habitual resident of Burma, Haiti, Syria, or
Venezuela filing an initial application for TPS. All other
applicants and re-registrants must submit a paper Form I821. If you submit online and are not allowed to, your
application may be denied.
link to www.uscis.gov/i-821
We will add Form I-765 for you to complete after you sign
your Form I-821. After your Form I-821 is signed, it will be
locked and no further changes can be made. Once both
forms are complete, you can pay for and submit the forms
at the same time.

h2. There are errors in (Section): (Sub section)
Edit my response

821-Alerts

I-765: Alerts

Number

Section

About You, Additional
information
Getting Started, Basis of
eligibility

Type

Logic

User selects "No" to
consent statement
Yellow alert regarding SSN
Yellow alert Always displays

Message

Notes

h2. You must agree to the Consent for Disclosure
To receive a Social Security card, you must select "Yes" to the
Consent for Disclosure.
h2. You can file your request online only for certain eligibility
categories

https://www.uscis.gov/sites/default/files/document/forms/i765instr.pdf

If your eligibility category does not appear on the drop-down list,
you must file a paper Form I-765. If you submit online and are not
eligible for one of the listed categories, your application may be
denied.

Getting Started, Basis of
eligibility

Getting Started,
Additional information
Review and Submit

Yellow alert If user selects (a)(12) h2. Only certain TPS applicants may apply online
To apply under this eligibility category online, you must be an
eligible national or habitual resident of Burma, Haiti, Syria, or
Venezuela filing an initial application for TPS. If you do not meet
these requirements, please submit a paper Form I-765. If you file
online and you are not allowed to, we may deny your application.

User selects "Yes" to
"Do you want the
SSA to issue you a
Yellow alert Social Security card"
If user has not
answered required
Red alert
field

h2. You must agree to the Consent for Disclosure
f you answer “Yes”, you must also answer “Yes” to the Consent for
Disclosure.
h2. There are errors in (Section): (Sub section)
Edit my response

765-Alerts

File Type	application/pdf
File Title	Copy of I-130 Form Copydeck 6.18.19- acaOCC 062719
Author	Microsoft Office User
File Modified	2021-06-22
File Created	2021-06-22