Form I-821D Application for Deferred Action for Childhood Arrivals

Consideration of Deferred Action
for Childhood Arrivals

USCIS
Form I-821D

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0124
Expires 03/31/2023

Receipt

A-

Action Block

For
USCIS Case ID:
Use
Requestor interviewed
Only
on

Resubmitted:

/
/

/
/

/

NOT FOR

Relocated

/

Returned:

/

Received:
Sent:

/

/

/

/ Remarks
/

To Be Completed by an Attorney or
Accredited Representative, if any.

Select this box if Form G-28 is attached to
represent the requestor.

Attorney State Bar Number (if any):

► START HERE - Type or print in black ink. Read Form I-821D Instructions for information on how to complete this form.

Part 1. Information About You (For Initial and
Renewal Requests)
I am not in immigration detention.

U.S. Mailing Address (Enter the same address on
Form I-765)
4.a. In Care Of Name (if applicable)

I am in immigration detention.
I am requesting:
Initial Request - Consideration of Deferred Action
for Childhood Arrivals

1.

4.c. Apt.

OR
2.
AND

4.b. Street Number
and Name

Renewal Request - Consideration of Deferred
Action for Childhood Arrivals

Ste.

Flr.

4.d. City or Town
4.e. State

4.f. ZIP Code

PRODUCTION

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)

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)?
Yes

3.c. Middle Name

No

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.

07/01/2022
Form I-821D Edition 08/31/21

Page 1 of 7

Part 1. Information About You (For Initial and
Renewal Requests) (continued)
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.

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)

NOT FOR
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)

Most Recent Date of Proceedings
(mm/dd/yyyy) ►

White
Asian
Black or African American

6.g. Location of Proceedings

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Other Information
7.

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

8.

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

9.

Date of Birth

10.

Gender

18.

Height

19.

Weight

20.

Eye Color (Select only one box)

(mm/dd/yyyy) ►

Inches
Pounds

Black

Blue

Brown

Gray
Maroon

Green
Pink

Hazel
Unknown/Other

PRODUCTION
Male

Female

11.a. City/Town/Village of Birth

21.

11.b. Country of Birth

12.

Current Country of Residence

13.

Country of Citizenship or Nationality

Marital Status
Married

Hair Color (Select only one box)
Bald (No hair)

Black

Blond

Brown
Sandy

Gray
White

Red
Unknown/
Other

Part 2. Residence and Travel Information (For
Initial and Renewal Requests)

07/01/2022
1.

14.

Feet

Widowed

Form I-821D Edition 08/31/21

Single

I have been continuously residing in the U.S. since at least
June 15, 2007, up to the present time.
No
Yes

Divorced

Page 2 of 7

Part 2. Residence and Travel Information (For
Initial and Renewal Requests) (continued)
NOTE: If you departed the United States for some period of
time before your 16th birthday and returned to the United States
on or after your 16th birthday to begin your current period of
continuous residence, and if this is an initial request, submit
evidence that you established residence in the United States
prior to 16 years of age as set forth in the instructions to this
form.

Address 3
5.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►
5.b. Street Number
and Name
5.c. Apt.

Ste.

Flr.

NOT FOR

For Initial Requests: List your current address and, to the best
of your knowledge, the addresses where you resided since the
date of your initial entry into the United States to present.

5.d. City or Town
5.e. State

5.f. ZIP Code

Travel Information

For Renewal Requests: List only the addresses where you
resided since you submitted your last Form I-821D that was
approved.

For Initial Requests: List all of your absences from the United
States since June 15, 2007.

If you require additional space, use Part 8. Additional
Information.

For Renewal Requests: List only your absences from the
United States since you submitted your last Form I-821D that
was approved.

Present Address
2.a. Dates at this residence (mm/dd/yyyy)
From ►
To ► Present
2.b. Street Number
and Name
2.c. Apt.

Ste.

Flr.

If you require additional space, use Part 8. Additional
Information.
Departure 1
6.a. Departure Date

(mm/dd/yyyy) ►

6.b. Return Date

(mm/dd/yyyy) ►

6.c. Reason for Departure

2.d. City or Town

PRODUCTION
2.f. ZIP Code

2.e. State

Departure 2

Address 1

3.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►
3.b. Street Number
and Name
3.c. Apt.

Ste.

7.a. Departure Date

(mm/dd/yyyy) ►

7.b. Return Date

(mm/dd/yyyy) ►

7.c. Reason for Departure
Flr.
8.

3.d. City or Town
3.f. ZIP Code

3.e. State

07/01/2022

Address 2

4.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►

Ste.

9.b. Passport Number

9.c. Passport Expiration Date

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

Have you left the United States without advance parole on
or after August 15, 2012?
Yes
No
9.a. What country issued your last passport?

(mm/dd/yyyy) ►
Flr.

10.

Border Crossing Card Number (if any)

4.d. City or Town
4.e. State

4.f. ZIP Code

Form I-821D Edition 08/31/21

Page 3 of 7

Part 3. For Initial Requests Only
1.

I initially arrived and established residence in the U.S.
prior to 16 years of age.
Yes
No

2.

Date of Initial Entry into the United States (on or about)
(mm/dd/yyyy) ►

3.

Place of Initial Entry into the United States

4.

Immigration Status on June 15, 2012 (e.g., No Lawful
Status, Status Expired, Parole Expired)

9.d. Type of Discharge

Part 4. Criminal, National Security, and Public
Safety Information (For Initial and Renewal
Requests)
If any of the following questions apply to you, use Part 8.
Additional Information to describe the circumstances and
include a full explanation.

NOT FOR
1.

5.a. Were you EVER issued an Arrival-Departure Record
(Form I-94, I-94W, or I-95)?
Yes
No
5.b. If you answered "Yes" to Item Number 5.a., provide
your Form I-94, I-94W, or I-95 number (if available).

If you answered “Yes,” you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest, unless
disclosure is prohibited under state law.

►
5.c. If you answered "Yes" to Item Number 5.a., provide the
date your authorized stay expired, as shown on Form I-94,
I-94W, or I-95 (if available).

2.

(mm/dd/yyyy) ►

Indicate how you meet the education guideline (e.g.,
Graduated from high school, Received a general
educational development (GED) certificate or equivalent
state-authorized exam, Currently in school)

Have you EVER been arrested for, charged with, or
convicted of a crime in any country other than the United
States?
Yes
No
If you answered "Yes," you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest.

Education Information
6.

Have you EVER been arrested for, charged with, or
convicted of a felony or misdemeanor, including incidents
handled in juvenile court, in the United States? Do not
include minor traffic violations unless they were alcoholor drug-related.
Yes
No

PRODUCTION
3.

Have you EVER engaged in, do you continue to engage
in, or plan to engage in terrorist activities?
Yes

7.

8.

Name, City, and State of School Currently Attending or
Where Education Received

Date of Graduation (e.g., Receipt of a Certificate of
Completion, GED certificate, other equivalent stateauthorized exam) or, if currently in school, date of last
attendance. (mm/dd/yyyy) ►

4.

Are you NOW or have you EVER been a member of a
gang?
Yes
No

5.

Have you EVER engaged in, ordered, incited, assisted, or
otherwise participated in any of the following:

5.a. Acts involving torture, genocide, or human trafficking?
Yes
No
5.b. Killing any person?

07/01/2022

Military Service Information
9.

Were you a member of the U.S. Armed Forces or U.S.
Coast Guard?
Yes
No

If you answered "Yes" to Item Number 9., you must provide
responses to Item Numbers 9.a. - 9.d.

5.c. Severely injuring any person?

9.c. Discharge Date

(mm/dd/yyyy) ►

Form I-821D Edition 08/31/21

Yes

No

Yes

No

5.d. Any kind of sexual contact or relations with any person
who was being forced or threatened?
Yes
No
6.

Have you EVER recruited, enlisted, conscripted, or used
any person to serve in or help an armed force or group
while such person was under age 15?
Yes
No

7.

Have you EVER used any person under age 15 to take
part in hostilities, or to help or provide services to people
in combat?
Yes
No

9.a. Military Branch

9.b. Service Start Date (mm/dd/yyyy) ►

No

Page 4 of 7

Part 5. Statement, Certification, Signature, and
Contact Information of the Requestor (For Initial
and Renewal Requests)

2.a. Requestor's Signature

2.b. Date of Signature (mm/dd/yyyy) ►

NOTE: Select the box for either Item Number 1.a. or 1.b.
1.a.

1.b.

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.

Requestor's Contact Information
3.

Requestor's Daytime Telephone Number

NOT FOR

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

,
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.

4.

Requestor's Mobile Telephone Number

5.

Requestor's Email Address

Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests)
Interpreter's Full Name
Provide the following information concerning the interpreter:
1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

PRODUCTION

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.

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

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

Ste.

Flr.

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

3.e. ZIP Code

07/01/2022

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.

Form I-821D Edition 08/31/21

3.f.

Province

3.g. Postal Code

3.h. Country

Page 5 of 7

Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests) (continued)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

Interpreter's Contact Information
3.c. City or Town
4.

Interpreter's Daytime Telephone Number
3.d. State

5.

3.e. ZIP Code

NOT FOR

Interpreter's Email Address

3.f.

Province

3.g. Postal Code

Interpreter's Certification
I certify that:
I am fluent in English and

3.h. Country

which

is the same language provided in Part 5., Item Number 1.b.;

Preparer's Contact Information

I have read to this requestor each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 5., Item Number 1.b.; and

4.

Preparer's Daytime Telephone Number

The requestor has informed me that he or she understands each
and every instruction and question on the form, as well as the
answer to each question.

5.

Preparer's Fax Number

6.

Preparer's Email Address

6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy) ►

Preparer's Declaration

PRODUCTION

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
If Other than the Requestor (For Initial and
Renewal Requests)
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

I declare that I prepared this Form I-821D at the requestor's
behest, and it is based on all the information of which I have
knowledge.
7.a. Preparer's Signature

7.b. Date of Signature (mm/dd/yyyy) ►
NOTE: If you need extra space to complete any item within
this request, see the next page for Part 8. Additional
Information.

07/01/2022

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name

Form I-821D Edition 08/31/21

Page 6 of 7

Part 8. Additional Information (For Initial and
Renewal Requests)
If you need extra space to complete any item within this
request, use the space below. You may also make copies of this
page to complete and file with this request. Include your name
and A-Number (if any) at the top of each sheet of paper;
indicate the Page Number, Part Number, and Item Number
to which your answer refers; and sign and date each sheet.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

NOT FOR

Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

A-Number (if any)
► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.
5.a. Page Number

5.b. Part Number

5.c. Item Number

PRODUCTION
5.d.

07/01/2022
Form I-821D Edition 08/31/21

Page 7 of 7