I-881 Application for Suspension of Deportation or Special Rul

Application for Suspension of Deportation or
Special Rule Cancellation of Removal

USCIS
Form I-881

(Pursuant to Section 203 of Public Law 105-100, NACARA)

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

Receipt

OMB No. 1615-0072
Expires 12/31/2023

Decision

EOIR Actions

Granted suspension of deportation or
special rule cancellation of removal and
adjustment of status

Resubmitted

For
USCIS
Use Reloc Sent
Only

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Referred to Immigration Judge in
accordance with 8 CFR Section 240.70

(Adjudicating Officer's Signature)

Reloc Rec'd

(Date of Action)

To be completed by an
Attorney or Accredited
Representative (if any).

Select this box if
Form G-28 is
attached.

(Office Location)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

U.S. Mailing Address

Your Current Legal Name

4.a. In Care Of Name (if any)

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

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

Apt.

Ste.

Flr.

1.c. Middle Name

4.d. City or Town

Other Names You Have Used Since Birth
(if applicable)

Provide all other names you have ever been known by or used,
including aliases, maiden name, and nicknames. Make sure to
include all variations of your name as it appears on identity
documents, passports, birth certificates, bank loan documents,
etc. If you need extra space to complete this section, use the
space provided in Part 15. Additional Information.

4.e. State

4.f.

ZIP Code

Other Information About You
5.

Date of Birth (mm/dd/yyyy)

6.

Gender

7.

City or Town of Birth

8.

Country of Birth

9.

Country of Citizenship or Nationality

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

10.

Alien Registration Number (A-Number/USCIS Number)
(if any)
A-

3.c. Middle Name

11.

USCIS Online Account Number (if any)
►

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

Form I-881 Edition 12/02/21

Male

Female

Page 1 of 14

Part 1. Information About You (continued)
12.

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

NOTE: If you selected either checkbox in Item Number 4.,
attach evidence of the relationship and provide the following
information about the spouse or parent who has already applied
or is currently filing with you:
Spouse or Parent's Name

Part 2. Application Type
I am eligible to apply for suspension of deportation or special
rule cancellation of removal under the Nicaraguan Adjustment
and Central American Relief Act (NACARA) because I have
not been convicted of an aggravated felony and (Select all
applicable boxes in Item Numbers 1. - 4.):
1.

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Registered ABC Class Members

I am a national of El Salvador who first entered the
United States on or before September 19, 1990 and
registered for benefits on time under the ABC
settlement agreement in American Baptist Churches
v. Thornburgh, 760 F. Supp. 796 (N.D. Cal. 1991),
either directly or by applying for Temporary
Protected Status (TPS) between January 1, 1991 and
October 31, 1991; and I have not been apprehended
at the time of entry after December 19, 1990.

I am a national of Guatemala who first entered the United
States on or before October 1, 1990, and registered for
benefits on time under the ABC settlement agreement in
American Baptist Churches v. Thornburgh, 760 F. Supp.
796 (N.D. Cal. 1991), and I have not been apprehended
at the time of entry after December 19, 1990.

2.
3.

4.

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

I am a national of Guatemala or El Salvador who filed
an application for asylum on or before April 1, 1990.
I entered the United States on or before December
31, 1990; filed an application for asylum on or before
December 31, 1991; and, at the time of filing, was a
national of the Soviet Union (USSR), Russia, any
republic of the former Soviet Union, Latvia, Estonia,
Lithuania, Poland, Czechoslovakia, Romania,
Hungary, Bulgaria, Albania, East Germany, or any
state of the former Yugoslavia.

Spouse, child, son, or daughter of someone who has
already applied or is currently filing for suspension of
deportation or special rule cancellation of removal
under NACARA:
I am the spouse or child (unmarried and under 21 years
of age) of someone who has already applied, or who is
currently filing with me, for suspension of deportation or
special rule cancellation of removal under NACARA.
I am the unmarried son or unmarried daughter of someone
who has already applied or who is currently filing with me,
for suspension of deportation or special rule cancellation of
removal under NACARA, and I entered the United States
on or before October 1, 1990, or my parent was granted
suspension of deportation or special rule cancellation of
removal when I was under 21 years of age.

Form I-881 Edition 12/02/21

5.c. Middle Name

A-

6.

A-Number (if any)

7.

The person who has applied for suspension of deportation
or special rule cancellation of removal is your:
Spouse
Parent

8.

I am or was the spouse or child of an individual
described in Item Numbers 1. - 3., and I or my child
has been battered or subjected to extreme cruelty by
that individual described in Item Numbers 1. - 3.

Part 3. Information About Your Presence In the
United States
Address History

Provide your physical addresses for the last 10 years. Include
addresses for anywhere you resided 60 days or more. Provide
your current address first. If you need extra space to complete
this section, use the space provided in Part 15. Additional
Information.
Physical Address 1 (current address)
1.a. Street Number
and Name
1.b.

Apt.

Ste.

Flr.

1.c. City or Town
1.d. State

1.e. ZIP Code

Date of Residence
2.a. From (mm/dd/yyyy)
2.b. To (mm/dd/yyyy)

Page 2 of 14

Part 3. Information About Your Presence In the
United States (continued)
Physical Address 2
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town

Information About Your Departures From and To
the United States
Provide information about any departure from and return to the
United States you have made since your first entry into the U.S.
List all departures, including short trips that lasted longer than
24 hours and visits to Canada and Mexico. If you need extra
space to complete this section, use the space provided in Part
15. Additional Information.
NOTE: If you have not departed the United States since your
first date of entry, type or print “None” below.

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3.d. State

3.e. ZIP Code

Departure 1 (current or most recent)

Date of Residence

13.

Port of Departure

14.

Departure Date (mm/dd/yyyy)

15.

Purpose of Travel

16.

Destination

4.a. From (mm/dd/yyyy)
4.b. To (mm/dd/yyyy)

Information About Your First Entry Into the
United States
Name Used When You First Entered the United States
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

Return 1
17.

Port of Entry

18.

Return Date (mm/dd/yyyy)

19.

Status at Entry

20.

Inspected and Admitted

21.

Immigration Status in Which You Were Admitted

22.

If you were admitted in a nonimmigrant status, were you
granted a change of status after you were admitted?

5.c. Middle Name
6.

Place of First Entry Into the United States

7.

Status When You First Entered the United States

8.

Date of First Entry Into the United States (mm/dd/yyyy)

Period Admitted Into the United States
9.a. From (mm/dd/yyyy)
9.b. To (mm/dd/yyyy)

Yes

Yes
23.

No

No

Which nonimmigrant status did you obtain?

10.a. Did you change your nonimmigrant status after entry?
Yes
No
10.b. If you answered “Yes,” which nonimmigrant status did
you obtain?

11.

Date You First Changed Status (mm/dd/yyyy)

12.

Date Your Last Extension of Stay Expired (mm/dd/yyyy)

Form I-881 Edition 12/02/21

Page 3 of 14

Part 3. Information About Your Presence In the
United States (continued)

35.d. Departed the United States under a grant of voluntary
departure or voluntary return?
Yes
No

Departure 2

35.e. Failed to appear for deportation or removal?
Yes

24

Port of Departure

25.

Departure Date (mm/dd/yyyy)

26.

Purpose of Travel

No

Part 4. Information About Your Employment
and Financial Status

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Employment History

27.

Provide your employment history for the last 10 years. List
your employment from most recent to the oldest, starting with
information on your current employment first. Include all
employment, even if it is not full-time. If you did the same type
of work for three or more employers during any six-month
period and you do not know the names and addresses of those
employers, you may type or print “multiple employers.” You
should specify any periods of unemployment, unpaid work
(such as a homemaker or intern), or school attendance. If you
need extra space to complete this section, use the space
provided in Part 15. Additional Information.

Destination

Return 2
28.

Port of Entry

29.

Return Date (mm/dd/yyyy)

30.

Status at Entry

Employer 1 (current or most recent)

31.

Inspected and Admitted

Yes

No

32.

Immigration Status in Which You Were Admitted

33.

If you were admitted in a nonimmigrant status, were you
granted a change of status after you were admitted?

1.

Name of Employer or Company

Address of Employer/Company

Yes

34.

No

2.a. Street Number
and Name
2.b.

Apt.

Ste.

Flr.

Which nonimmigrant status did you obtain?

2.c. City or Town

If you answer “Yes” or are unsure about any of your answers to
any of the questions in Item Numbers 35.a. - 35.e., use the
space provided in Part 15. Additional Information to provide
an explanation.

2.f.

2.e. ZIP Code

Province

2.g. Postal Code
2.h. Country

Have you EVER:
35.a. Been ordered deported or removed?

2.d. State

Yes

No

35.b. Departed the United States under an order of deportation
or removal?
Yes
No
35.c. Overstayed a grant of voluntary departure from an
immigration judge or the Department of Homeland
Security (DHS)?
Yes
No

Form I-881 Edition 12/02/21

Page 4 of 14

Part 4. Information About Your Employment
and Financial Status (continued)
3.

Earnings Per Week (U.S. dollars)

4.

Your Occupation

$

Dates of Employment

Financial Status
Provide information about your assets in the United States and other
countries, including those held jointly with your spouse (if you are
married) or with others. Do not include the value of clothing and
household necessities. If married, provide information about your
spouse's assets that he or she does not hold jointly with you. If you
need extra space to complete this section or to describe other assets
listed, use the space provided in Part 15. Additional Information.

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Self (Including assets jointly owned with spouse or others)

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

11.a. Cash, Checking, or Savings Accounts (U.S. dollars)

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

$

11.b. Motor Vehicles (Minus any amount owed) (U.S. dollars)

Employer 2

$

6.

Name of Employer or Company

11.c. Real Estate (Minus any amount owed) (U.S. dollars)
$

Address of Employer/Company

11.d. Other (U.S. dollars)

7.a. Street Number
and Name
7.b.

Apt.

$

Ste.

11.e. Total (U.S. dollars)

Flr.

$

7.c. City or Town

Spouse (if applicable)

7.d. State
7.f.

7.e. ZIP Code

12.a. Cash, Checking, or Savings Accounts (U.S. dollars)
$

Province

12.b. Motor Vehicles (Minus any amount owed) (U.S. dollars)

7.g. Postal Code

$

7.h. Country

12.c. Real Estate (Minus any amount owed) (U.S. dollars)
$

8.

Earnings Per Week (U.S. dollars)

9.

Your Occupation

$

12.d. Other (U.S. dollars)
$

12.e. Total (U.S. dollars)
$

Dates of Employment
10.a. From (mm/dd/yyyy)
10.b. To (mm/dd/yyyy)

Form I-881 Edition 12/02/21

13.a. Have you filed a Federal income tax return while in the
United States?
Yes
No
13.b. If you answered "Yes," indicate the years you filed and
attach evidence that you filed the returns. If you did not file
a tax return during any particular years, explain why you did
not file. If you need extra space to complete this section,
use the space provided in Part 15. Additional Information.

Page 5 of 14

Part 5. Information About Your Marital Status
and Spouse
1.

What is your current marital status?
Single, Never Married

Married

Divorced

Widowed

Marriage Annulled

Legally Separated

Address Where Current Spouse Resides
8.a. Street Number
and Name
8.b.

Apt.

Ste.

Flr.

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

8.e. ZIP Code

Province

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Information About Your Current Marriage
(including if you are legally separated)

If you are currently married, provide the following information
about your current spouse.

8.g. Postal Code
8.h. Country

Current Spouse's Legal Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Current Spouse's Status
9.

If your spouse presently resides in the United States, your
spouse's present status is:
U.S. Citizen

2.c. Middle Name

Lawful Permanent Resident

A-

3.

A-Number (if any)

4.

Current Spouse's Date of Birth (mm/dd/yyyy)

5.

Current Spouse's Date of Marriage (mm/dd/yyyy)

Asylee

Asylum Applicant
Other (explain):

Current Spouse's Employment

Current Spouse's Place of Birth

10.

Is your spouse employed?

Yes

No

6.a. City or Town

If your spouse is employed, provide your spouse's name,
address of employment, and his or her salary.

6.b. State or Province

11.

Name of Employer/Company

6.c. Country
Address of Employer/Company
Current Spouse's Place of Marriage

12.a. Street Number
and Name

7.a. City or Town

12.b.

Apt.

Ste.

Flr.

12.c. City or Town
7.b. State or Province

7.c. Country

12.d. State

12.e. ZIP Code

12.f. Province
12.g. Postal Code
12.h. Country

Form I-881 Edition 12/02/21

Page 6 of 14

Part 5. Information About Your Marital Status
and Spouse (continued)

22.

Manner in Which Marriage to Prior Spouse Was
Terminated or Ended
Divorce

13.

Earnings per Week (U.S. dollars)

14.

Your Spouse's Occupation

$

Death
Annulment
Other

Dates of Employment

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23.

15.a. From (mm/dd/yyyy)
15.b. To

PRESENT

Information About Your Previous Marriage
(if applicable)
16.

Have you been ordered by any court or are you otherwise
under any legal obligation to provide child support and/or
spousal maintenance?
Yes
No

If you answered "Yes," use the space provided in Part 15.
Additional Information to explain what type of obligation you
have, to whom it is owed, and whether you are fulfilling that
obligation.

How many times have you been married?

If you were previously married, provide the following
information about your prior spouses. If you have had more
than one previous marriage, use the space provided in Part 15.
Additional Information to provide the information below.

Part 6. Information About Your Children

1.a. Do you have children?

Yes

No

If you answered "No," then skip to Part 7.

Prior Spouse's Legal Name
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)

17.c. Middle Name
18.

Prior Spouse's Date of Birth (mm/dd/yyyy)

19.

Date of Marriage to Prior Spouse (mm/dd/yyyy)

20.

Date Marriage to Prior Spouse Ended (mm/dd/yyyy)

1.b. How many children do you have?

List all your children below, regardless of their age, and provide
the requested information about each of them. If your child
currently resides with you, please type or print “with me” under
“current address.” If the child does not live with you, provide
his or her address and relationship to the person with whom he
or she lives. If you need extra space to complete this section,
use the space provided in Part 15. Additional Information.

Child 1

Child's Current Legal Name

Place Where Marriage to Prior Spouse Ended

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

21.a City or Town

2.c. Middle Name

21.b. State or Province

21.c. Country

Form I-881 Edition 12/02/21

A-

3.

A-Number (if any)

4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

6.

Immigration Status

Page 7 of 14

Part 6. Information About Your Children
(continued)
7.a. Street Number
and Name
Apt.

Ste.

Flr.

7.c. City or Town

14.c. Middle Name

A-

15.

A-Number (if any)

16.

Date of Birth (mm/dd/yyyy)

17.

Country of Birth

18.

Immigration Status

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7.d. State
7.f.

Child's Current Legal Name
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)

Child's Current Address

7.b.

Child 3

7.e. ZIP Code

Province

7.g. Postal Code
7.h. Country

Child 2

Child's Current Address
19.a. Street Number
and Name

Child's Current Legal Name

19.b.

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

Apt.

Ste.

Flr.

19.c. City or Town
19.d. State

8.c. Middle Name

A-

9.

A-Number (if any)

10.

Date of Birth (mm/dd/yyyy)

11.

Country of Birth

12.

Immigration Status

19.e. ZIP Code

19.f. Province

19.g. Postal Code
19.h. Country

Part 7. Information About Your Parents

Child's Current Address

Information About Your Parent 1

13.a. Street Number
and Name

Parent 1's Legal Name

13.b.

Apt.

Ste.

Flr.

13.c. City or Town
13.d. State

13.e. ZIP Code

13.f. Province
13.g. Postal Code
13.h. Country

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Parent 1's Name at Birth (if different than above)
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name

Form I-881 Edition 12/02/21

Page 8 of 14

Part 7. Information About Your Parents
(continued)
A-

3.

A-Number (if any)

4.

Date of Birth (mm/dd/yyyy)

5.

City or Town of Birth

6.

Country of Birth

7.

Immigration Status

8.

Country of Citizenship or Nationality

A-

14.

A-Number (if any)

15.

Date of Birth (mm/dd/yyyy)

16.

City or Town of Birth

17.

Country of Birth

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18.

Immigration Status

19.

Country of Citizenship or Nationality

Current Address

20.a. Street Number
and Name

Current Address

20.b.

9.a. Street Number
and Name

20.c. City or Town

9.b.

Apt.

Ste.

Flr.

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

Apt.

20.d. State

Ste.

Flr.

20.e. ZIP Code

20.f. Province

9.e. ZIP Code

Province

20.g. Postal Code
20.h. Country

9.g. Postal Code
9.h. Country

10.

Estimated Total Assets (U.S. dollars)

11.

Weekly Earnings (U.S. dollars)

21.

Estimated Total Assets (U.S. dollars)

22.

Weekly Earnings (U.S. dollars)

Part 8. Biographic Information
1.

Ethnicity (Select only one box)

Information About Your Parent 2

Hispanic or Latino

Parent 2's Legal Name

Not Hispanic or Latino

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

2.

Race (Select all applicable boxes)
American Indian or Alaska Native
Asian

12.c. Middle Name

Black or African American
Parent 2's Name at Birth (if different than above)

Native Hawaiian or Other Pacific Islander

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

White

13.c. Middle Name
Form I-881 Edition 12/02/21

3.

Height

4.

Weight

Feet

Inches
Pounds
Page 9 of 14

2.g. Trafficked a controlled substance, or knowingly assisted,
abetted, conspired, or colluded with others in any such
trafficking (not including a single offense of simple
possession of 30 grams or less of marijuana)?
Yes
No

Part 8. Biographic Information (continued)
5.

6.

Eye Color (Select only one box)
Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)

2.h. Been a practicing polygamist?
2.i.

Bald (No hair)

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Yes

Been admitted into the United States as a crewman after
June 30, 1964?
Yes
No

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2.j.

Been admitted into the United States as an exchange
visitor or acquired such status after arriving in the U.S.?
Yes

Part 9. Miscellaneous Information

Respond to the following questions. If you answer "Yes" to any
of the questions in Item Numbers 1. - 2.m., use the space
provided in Part 15. Additional Information to provide an
explanation.
1.

Have you ever (either in the United States or in another
country) been arrested, summoned into court as a
defendant, convicted, fined, imprisoned, placed on
probation, or forfeited collateral for an act involving a
felony, misdemeanor, or breach of any public law or
ordinance (including, but not limited to, driving violations
involving alcohol)?
Yes
No
If you answered "Yes," your explanation must include a
brief description of each offense, including the name and
location of the offense, date of conviction, any penalty
imposed, any sentence imposed, and the time actually
served.

Have you EVER:

2.a. Been a habitual drunkard?

Yes

No

2.b. Derived income principally from illegal gambling?
Yes
2.c. Given false testimony for the purpose of obtaining
immigration benefits?
Yes

No

No

2.d. Engaged in prostitution or unlawful commercialized vice?
Yes

No

2.e. Been involved in a serious criminal offense and asserted
immunity from prosecution?
Yes
No
2.f.

No

No

2.k. Been inadmissible or deportable on security-related
grounds under the Immigration and Nationality Act (INA)
sections 212(a)(3) or 237(a)(4) (for cancellation
applicants), or under pre-IIRIRA INA section 241(a)(4)
(for suspension applicants)?
Yes
No
2.l.

Ordered, incited, assisted, or otherwise participated in the
persecution of an individual on account of his or her race,
religion, nationality, membership in a particular social
group, or political opinion?
Yes
No

2.m. Been previously granted relief under INA sections 212(c)
(waiver for certain grounds of inadmissibility) or 244(a)
(suspension of deportation) or was your removal
cancelled under INA section 240A (cancellation of
removal)?
Yes
No

Part 10. Information About Hardship You and/
or Your Family Will Face If You Are Deported
or Removed from the United States

Your responses in this part should be about you and/or your
qualifying family members, except for your response to Item
Number 11. A qualifying family member is a parent, spouse,
or child who is a U.S. citizen (USC) or a lawful permanent
resident (LPR) of the United States. When providing responses
about a family member, provide the family member's name and
his or her relationship to you. Where required, provide an
explanation of your answer in the space provided in Part 15.
Additional Information and reference the Item Number for
which you are providing an explanation. Attach any documents
you have to support the responses you provide below. (See the
Instructions for types of documents that you may wish to
submit.)

Aided and/or abetted another person to enter the United
States illegally?
Yes
No

Form I-881 Edition 12/02/21

Page 10 of 14

Part 10. Information About Hardship You and/
or Your Family Will Face If You Are Deported
or Removed from the United States (continued)
NOTE: If you meet the eligibility requirements listed under
Part 2. Application Type and you complete this application,
you will be presumed to meet the extreme hardship requirement
unless the evidence in your case record establishes that neither
you nor your qualified relative are likely to experience extreme
hardship if you are deported or removed from the United States.
If you qualify for a presumption of extreme hardship, you do
not need to submit documents that support your answers below
regarding your claim to extreme hardship, but you need to
provide explanations to your answers below.

If you are deported or removed from the United States,
would all qualified family members accompany you?
Yes

No

Not applicable

If you answered "No," list which qualified family
members would not accompany you, why the qualified
family members would not accompany you, and how that
affects you and your family members.
7.

Would you or your qualified family members experience
any emotional or psychological impact if you were
deported or removed from the United States?

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1.

If your children are American citizens or lawful
permanent residents, do your children speak, read, and
write English?
Not applicable
Yes
No

2.

If your children are American citizens or lawful
permanent residents, do your children speak, read, and
write the native language of the country you would be
returned to if deported or removed?
Not applicable
Yes
No

3.

Do you or any of your qualified family members suffer
from or have previously suffered from any illness, health
problem, or disability that requires or required medical
attention?
Not applicable
Yes
No

If you answered "Yes," provide information about the
health problem and whether you or your qualified family
member suffer or have suffered from it. Also include any
care you or the person receives in the United States that
would not be available in the country to which you would
be deported or removed.
4.

6.

Would you be able to obtain employment in the country
to which you would be deported or removed?
Yes

No

Yes

No

Not applicable

8.

Would the current conditions in the country to which you
would be deported or removed cause you or your
qualified family members extreme hardship if you are
deported or removed?
Yes
No
Not applicable

9.

Do you currently have any other way, besides this
application, for suspension of deportation or special rule
cancellation of removal, to adjust status to that of lawful
permanent resident in the United States?
Yes
No
Not applicable

10.

If you belong to any civic, political, religious, community,
or social organization, association, foundation, club, or
similar group or participate in volunteer activities, would
separating from these community ties and activities affect
you if you are deported or removed from the United States?
Yes

11.

No

Not applicable

Is there any other types of hardship that you or your
family would face if you are deported or removed from
the United States? (Include any hardship to your children,
spouse, parents who are not American citizens or lawful
permanent residents, and to your brothers, sisters,
grandparents, or other extended family members.)
Yes

No

Not applicable

Not applicable

If you answered "Yes," explain the type of employment
you would be able to obtain. If you answered "No,"
explain why you would be unable to find employment.
5.

If you or a qualified family member are currently
pursuing educational opportunities in the United States,
would you or the qualified family member continue to
pursue the educational opportunities if deported or
removed from the United States?
Yes

No

Not applicable

If you answered "No," explain why not.
Form I-881 Edition 12/02/21

Page 11 of 14

Part 11. Applicant's Contact Information,
Certification, and Signature

Part 12. Interpreter's Contact Information,
Certification, and Signature

Applicant's Contact Information

Interpreter's Full Name

Provide your daytime telephone number, mobile telephone
number (if any), and email address (if any).

1.

1.

Applicant's Daytime Telephone Number

2.

Applicant's Mobile Telephone Number (if any)

3.

Applicant's Email Address (if any)

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

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NOT FOR
PRODUCTION
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2.

Interpreter's Business or Organization Name

Interpreter's Contact Information

Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my application, I read and understand or, if interpreted to
me in a language in which I am fluent by the interpreter listed in
Part 12., understood, all of the responses and information
contained in, and submitted with, my application, and that all of
the responses and the information are complete, true, and
correct. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for an immigration request and to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration law.
4.
Applicant's Signature

Date of Signature (mm/dd/yyyy)

3.

Interpreter's Daytime Telephone Number

4.

Interpreter's Mobile Telephone Number (if any)

5.

Interpreter's Email Address (if any)

Interpreter's Certification and Signature

I certify, under penalty of perjury, that I am fluent in English and
,

and I have interpreted every question on the application and
Instructions and interpreted the applicant's answers to the
questions in that language, and the applicant informed me that
they understood every instruction, question, and answer on the
application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Form I-881 Edition 12/02/21

Page 12 of 14

Part 13. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Full Name
1.

Part 14. To Be Completed at Interview or
Hearing
You will be asked to complete Part 14. when you are before an
asylum officer or an immigration judge for examination.
1.

Preparer's Family Name (Last Name)

I swear (affirm) that I know the contents of this application
that I am signing, including the attached documents and
supplements, are
all true or
not all true to the
best of my knowledge and that the corrections numbered

DRAFT
NOT FOR
PRODUCTION
08/15/2023
to

Preparer's Given Name (First Name)

were made by me or

at my request.

2.

Preparer's Business or Organization Name

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

4.

Preparer's Mobile Telephone Number (if any)

5.

Preparer's Email Address (if any)

2.a. Applicant's Signature

2.b. Date of Signature (mm/dd/yyyy)
3.

Print your name in your native alphabet.

4.

Signed and sworn before me by the above-named
applicant on:
Date (mm/dd/yyyy)

5.a. Asylum Officer or Immigration Judge's Signature

Preparer's Certification and Signature

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

I certify, under penalty of perjury, that I prepared this
application for the applicant at their request and with express
consent and that all of the responses and information contained
in and submitted with the application are complete, true, and
correct and reflects only information provided by the applicant.
The applicant reviewed the responses and information and
informed me that they understand the responses and information
in or submitted with the application.
6.
Preparer's Signature

Date of Signature (mm/dd/yyyy)

Form I-881 Edition 12/02/21

Page 13 of 14

5.a. Page Number

Part 15. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
NOT FOR
PRODUCTION
08/15/2023

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.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-881 Edition 12/02/21

4.c. Item Number

7.a. Page Number

7.d.

Page 14 of 14