Pages 1-2,
Part 1. Information
About You (For
Initial and Renewal Requests)
|
[Page 1]
Part
1. Information About You
(For
Initial and
Renewal
Requests)
I
am not in immigration detention
and
I
have included Form I-765, Application for Employment
Authorization, and Form I-765WS, Form I-765 Worksheet; and
I
am requesting:
1.
Initial
Request
-
Consideration of Deferred Action for
Childhood Arrivals
OR
2.
Renewal Request -
Consideration of Deferred Action for Childhood Arrivals
AND
For
this Renewal request, my most recent period of Deferred Action for
Childhood Arrivals expires on (mm/dd/yyyy)
Full
Legal Name
3.a.
Family
Name (Last
Name)
3.b.
Given
Name (First
Name)
3.c.
Middle
Name
U.S.
Mailing Address
(Enter
the same address on
Form I-765)
4.a.
In
Care
Of
Name
(if
applicable)
4.b.
Street
Number
and
Name
4.c.
Apt. Ste. Flr.
4.d.
City
or Town
4.e.
State
4.f.
ZIP
Code
Removal
Proceedings Information
5.
Are
you NOW
or
have you EVER
been
in removal proceedings, or do you have a removal order issued in
any other context (for
example, at the border or within the United States by an
immigration agent)?
Y/N
NOTE:
The
term “removal proceedings” includes exclusion or
deportation proceedings initiated before April 1, 1997; an
Immigration and Nationality Act (INA) section 240 removal
proceeding; expedited removal; reinstatement of a final order of
exclusion, deportation, or removal; an INA section 217 removal
after admission under the Visa Waiver Program; or removal as a
criminal alien under INA section 238.
If
you answered "Yes" to Item
Number 5.,
you must select a box below indicating your current status or
outcome of your removal proceedings.
Status
or outcome:
5.a.
Currently
in Proceedings (Active)
5.b.
Currently
in Proceedings (Administratively
Closed)
5.c.
Terminated
5.d.
Subject
to a Final Order
5.e.
Other.
Explain in Part
8. Additional Information.
5.f.
Most
Recent Date of Proceedings (mm/dd/yyyy)
5.g.
Location
of Proceedings
[Page
2]
Other
Information
6.
Alien
Registration Number (A-Number) (if
any)
7.
U.S.
Social Security Number (if
any)
8.
Date
of Birth (mm/dd/yyyy)
9.
Gender
Male
Female
10.a.
City/Town/Village
of
Birth
10.b.
Country
of Birth
11.
Current
Country of Residence
12.
Country
of Citizenship or Nationality
13.
Marital
Status
Married
Widowed
Single
Divorced
Other
Names Used
(If
Applicable)
If
you need additional space, use Part
8. Additional
Information.
14.a.
Family
Name (Last
Name)
14.b.
Given
Name (First
Name)
14.c.
Middle
Name
Processing
Information
15.
Ethnicity (Select
only
one
box)
Hispanic
or Latino
Not
Hispanic or Latino
16.
Race
(Select
all
applicable
boxes)
White
Asian
Black
or African American
American
Indian or Alaska Native
Native
Hawaiian or Other Pacific Islander
17.
Height
Feet
Inches
18.
Weight
Pounds
19.
Eye
Color (Select
only
one
box)
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
20.
Hair
Color (Select
only
one
box)
Bald
(No hair)
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
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[Page 1]
Part
1. Information About You
(For
Initial and
Renewal
Requests)
[]
I
am
not
in immigration detention.
[]
I am
in immigration detention.
I
am requesting:
1.
Initial
Request
-
Consideration of Deferred Action for
Childhood Arrivals
OR
2.
Renewal Request -
Consideration of Deferred Action for Childhood Arrivals
AND
For
this Renewal request, my most recent period of Deferred Action for
Childhood Arrivals expires on (mm/dd/yyyy)
Full
Legal Name
3.a.
Family
Name (Last
Name)
3.b.
Given
Name (First
Name)
3.c.
Middle
Name
U.S.
Mailing Address
(Enter
the same address on
Form I-765)
4.a.
In
Care
Of
Name
(if
applicable)
4.b.
Street
Number
and
Name
4.c.
Apt. Ste. Flr.
4.d.
City
or Town
4.e.
State
4.f.
ZIP
Code
Removal
Proceedings Information
5.
Are
you NOW
or
have you EVER
been
in removal proceedings, or do you have a removal order issued in
any other context (for
example, at the border or within the United States by an
immigration agent)?
Y/N
NOTE:
The
term “removal proceedings” includes exclusion or
deportation proceedings initiated before April 1, 1997; an
Immigration and Nationality Act (INA) section 240 removal
proceeding; expedited removal; reinstatement of a final order of
exclusion, deportation, or removal; an INA section 217 removal
after admission under the Visa Waiver Program; or removal as a
criminal alien under INA section 238.
If
you answered "Yes" to Item
Number 5.,
you must select a box below indicating your current status or
outcome of your removal proceedings.
Status
or outcome:
6.a.
Currently
in Proceedings (Active)
6.b.
Currently
in Proceedings (Administratively
Closed)
6.c.
Terminated
6.d.
Subject
to a Final Order
6.e.
Other.
Explain in Part
8. Additional Information.
6.f.
Most
Recent Date of Proceedings (mm/dd/yyyy)
6.g.
Location
of Proceedings
[Page
2]
Other
Information
7.
Alien
Registration Number (A-Number) (if
any)
8.
U.S.
Social Security Number (if
any)
9.
Date
of Birth (mm/dd/yyyy)
10.
Gender
Male
Female
11.a.
City/Town/Village
of
Birth
11.b.
Country
of Birth
12.
Current
Country of Residence
13.
Country
of Citizenship or Nationality
14.
Marital
Status
Married
Widowed
Single
Divorced
Other
Names Used
(If
Applicable)
If
you need additional space, use Part
8. Additional
Information.
15.a.
Family
Name (Last
Name)
15.b.
Given
Name (First
Name)
15.c.
Middle
Name
Processing
Information
16.
Ethnicity (Select
only
one
box)
Hispanic
or Latino
Not
Hispanic or Latino
17.
Race
(Select
all
applicable
boxes)
White
Asian
Black
or African American
American
Indian or Alaska Native
Native
Hawaiian or Other Pacific Islander
18.
Height
Feet
Inches
19.
Weight
Pounds
20.
Eye
Color (Select
only
one
box)
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
21.
Hair
Color (Select
only
one
box)
Bald
(No hair)
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
|
Page 5,
Part 5. Statement,
Certification, Signature, and Contact Information of the Requestor
(For Initial
and Renewal Requests)
|
[Page
5]
Part
5. Statement, Certification, Signature, and Contact Information
of the Requestor
(For
Initial and Renewal Requests)
NOTE:
Select
the box for either Item
Number 1.a. or
1.b.
1.a.
I
can read and understand English, and have read and understand each
and every question and instruction on this form, as well as my
answer to each question.
1.b.
The
interpreter named in Part
6. has
read to me each and every question and instruction on this form,
as well as my answer to each question, in [Fillable Field], a
language in which I am fluent. I understand each and every
question and instruction on this form as translated to me by my
interpreter, and have provided true
and correct responses in the language indicated above.
Requestor's
Certification
[new]
I
certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct and that
copies
of documents submitted are exact photocopies of unaltered original
documents. I understand that I may be required to submit original
documents to U.S. Citizenship and Immigration Services (USCIS) at
a later date. I also understand that knowingly and willfully
providing materially false information on this form is a federal
felony punishable by a fine, imprisonment up to 5 years, or both,
under 18 U.S.C. section 1001. Furthermore, I authorize the
release of any information from my records that USCIS may need to
reach a determination on my deferred action request.
2.a.
Requestor's
Signature
2.b.
Date
of Signature (mm/dd/yyyy)
Requestor's
Contact Information
3.
Requestor's
Daytime Telephone Number
4.
Requestor's
Mobile Telephone Number
5.
Requestor's
Email Address
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[Page
5]
Part
5. Statement, Certification, Signature, and Contact Information
of the Requestor
(For
Initial and Renewal Requests)
NOTE:
Select
the box for either Item
Number 1.a. or
1.b.
1.a.
I
can read and understand English, and have read and understand each
and every question and instruction on this form, as well as my
answer to each question.
1.b.
The
interpreter named in Part
6. has
read to me each and every question and instruction on this form,
as well as my answer to each question, in [Fillable Field], a
language in which I am fluent. I understand each and every
question and instruction on this form as translated to me by my
interpreter, and have provided true
and correct responses in the language indicated above.
Requestor's
Declaration
and Certification
Copies
of any documents I have submitted are exact photocopies of
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my
eligibility for the request that I seek.
I
furthermore authorize release of information contained in this
request, 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.
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 provided or authorized all of the information in my
request;
2)
I understood all of the information contained in, and submitted
with, my request; and
3)
All
of this information was complete, true, and correct at the time of
filing.
I
certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct and that
copies
of documents submitted are exact photocopies of unaltered original
documents. I understand that I may be required to submit original
documents to U.S. Citizenship and Immigration Services (USCIS) at
a later date. I also understand that knowingly and willfully
providing materially false information on this form is a federal
felony punishable by a fine, imprisonment up to 5 years, or both,
under 18 U.S.C. section 1001. Furthermore, I authorize the
release of any information from my records that USCIS may need to
reach a determination on my deferred action request.
2.a.
Requestor's
Signature
2.b.
Date
of Signature (mm/dd/yyyy)
Requestor's
Contact Information
3.
Requestor's
Daytime Telephone Number
4.
Requestor's
Mobile Telephone Number
5.
Requestor's
Email Address
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