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I-821, Application for Temporary Protected Status (United States)

This form is to apply for temporary protected status in the United States. The form provided here is simply a sample of what the actual Form I-821 looks like.

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

I-821, Application for Temporary Protected Status



Returned ___________________ Date

Resubmitted ___________________ Date

Reloc Sent ___________________ Date

Reloc Rec'd ___________________ Date

Receipt ___________________

____ Applicant Interviewed on ___________________


Case ID # _______________________________

A # _______________________________


Action Block


To Be Completed By

Attorney or Representative, if any.

____ Fill in box if G-28 is attached to represent the petition.

ATTY State License # _______________________________


START HERE - Please type or print in black ink.

Part 1. Type of application. (check one)

a. ____ This is my first application to register for Temporary Protected Status (TPS).

b. ____ This is my application for re-registration or renewal of temporary treatment benefits. I have previously been granted TPS or temporary treatment benefits. I have maintained and continue to maintain eligibility for TPS.

Part 2. Information about you.

Family Name (Last Name) _______________________________

Given Name (First Name) _______________________________

Full Middle Name _______________________________

U.S. Mailing Address: (Street Number and Name) _______________________________

Apt. # _______________________________

C/O: (In Care Of) _______________________________

Town/City _______________________________

State _______________________________

County _______________________________

Zip Code _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

Gender ____ Male ____ Female

Place of Birth (Town or City) _______________________________

State/Country _______________________________

Country of Residence _______________________________

Country of Citizenship/Nationality _______________________________

Marital Status ____ Single ____ Married ____ Divorced ____ Widowed

Other Names Used (including maiden name) _______________________________

Date of Entry Into the U.S. (mm/dd/yyyy) _______________________________

Place of Entry Into the U.S. _______________________________

Manner of Arrival (Visitor, student, stowaway, without inspection, etc.) _______________________________

Arrival/Departure Record (I-94) No. _______________________________

Date authorized stay expired/or will expire, as shown on Form I-94 or I-95 (mm/dd/yyyy) _______________________________

Your Current Immigration Status:

In Status (state nonimmigrant classification; e.g., F-1, etc.) _______________________________

Out of Status (state nonimmigrant violation; e.g., overstay student, EWI, etc.) _______________________________

Alien Registration Number (A#) (if any) _______________________________

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

Are you now or have you ever been under immigration proceedings? ____ Yes ____ No

If you answered "Yes" to the above question, provide the following information.

Name under which you applied: _______________________________

Type of proceedings:

____ Exclusion ____ Removal/Deportation ____ Rescission ____ Judicial Proceedings

Location of Proceedings _______________________________

Date of Proceedings (mm/dd/yyyy) _______________________________

Part 3. Information about your spouse and children (if any).

1. Provide the following information about your spouse (if married).

Last Name of Spouse _______________________________

First Name _______________________________

Middle Name _______________________________

Address: (Street Number and Name) _______________________________

Apt. # _______________________________

Town/City _______________________________

State/Province _______________________________

Country _______________________________

Zip/Postal Code _______________________________

Your Spouse's Birth Date (mm/dd/yyyy) _______________________________

Date and Place of Present Marriage _______________________________

Name of Prior Husbands/Wives _______________________________

Date(s) Marriage(s) Ended (mm/dd/yyyy) _______________________________

2. List the names, ages and current residence of children (if any)

Name (First/Middle/Last) _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

Residence _______________________________

Name (First/Middle/Last) _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

Residence _______________________________

Name (First/Middle/Last) _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

Residence _______________________________

Part 4. Eligibility standards.

Provide the following information:

I am a national of, or an alien having no nationality, who last habitually resided in the foreign state of: _______________________________

I entered the United States on the following date (provide month/day/year), and have resided in the United States since that time. _______________________________

To be eligible for Temporary Protected Status, you must be admissible as an immigrant to the United States, with certain exceptions

If any of the questions beginning below on this page and continuing on Page 3 apply to you, number which one(s) in the box(es): (for example, 2k for Have you entered the United States as a stowaway;) and include a full explanation on a separate sheet(s) of paper. Use the number 2 before each letter referring to the specific question (2a, 2b, etc.).

If you were ever arrested, provide the disposition (outcome) of the arrest. For example, "case dismissed" from the appropriate authority. NOTE: For information about waivers concerning the grounds of inadmissibility, see Page 3.




2a. Have you been convicted of any felony or two or more misdemeanors committed in the United States?

2b. (i) Have you ordered, incited, assisted or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group or political opinion;

(ii) Have you been convicted by a final judgment of a particularly serious crime, constituting a danger to the community of the United States (an alien convicted of an aggravated felony is considered to have committed a particularly serious crime);

(iii) Have you committed a serious nonpolitical crime outside of the United States prior to your arrival in the United States; or

(iv) Have you engaged in or are you still engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States?

2c. (i) Have you been convicted of, or have you committed acts which constitute the essential elements of a crime (other than a purely political offense) or a violation of or a conspiracy to violate any law relating to a controlled substance as defined in Section 102 of the Controlled Substance Act;

(ii) Have you been convicted of two or more offenses (other than purely political offenses) for which the aggregate sentences to confinement actually imposed were five years or more;

(iii) Have you trafficked in or do you continue to traffic in any controlled substance or are or have been a knowing assister, abettor, conspirator, or colluder with others in the illicit trafficking of any controlled substance;

(iv) Have you engaged or do you continue to engage solely, principally, or incidentally in any activity related to espionage or sabotage or violate any law involving the export of goods, technology, or sensitive information, any other unlawful activity, or any activity the purpose of which is in opposition, or the control, or overthrow of the government of the United States;

(v) Have you engaged in or do you continue to engage in terrorist activities;

(vi) Have you engaged in or do you continue to engage or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States;

(vii) Have you been or do you continue to be a member of the Communist or other totalitarian party, except when membership was involuntary; and

(viii) Have you participated in Nazi persecution or genocide;

2d. Have you been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations, or been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action;

2e. Have you committed a serious criminal offense in the United States and asserted immunity from prosecution;

2f. Have you within the past ten years engaged in prostitution or procurement of prostitution or do you continue to engage in prostitution or procurement of prostitution;

2g. Have you been or do you intend to be involved in any other commercial vice;

2h. Have you been excluded and deported from the United States within the past year, or have you been deported or removed from the United States at government expense within the last five years (20 years if you have been convicted of an aggravated felony);

2i. Have you ever assisted any other person to enter the United States in violation of the law;

2j. (i) Do you have a communicable disease of public health significance.

(ii) Do you have or have you had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety or welfare of yourself or others;

(iii) Are you now or have you been a drug abuser or drug addict;

2k. Have you entered the United States as a stowaway;

2l. Are you subject to a final order for violation of section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act);

2m. Do you practice polygamy;

2n. Were you the guardian of, and did you accompany another alien who was ordered excluded and deported (or removed) from the United States;

2o. Have you detained, retained, or withheld the custody of a child, having a lawful claim to United States citizenship, outside the United States from a United States citizen granted custody?

NOTE ABOUT WAIVERS: If you placed any of the following numbered references in the boxes on Page 2, you may be eligible for a waiver of the grounds described in the questions: 2e; 2f; 2g; 2h; 2i; 2j; 2k; 2l; 2m; 2n or 2o. The Form I-601 is the USCIS application used to request a waiver. The form is available at local USCIS offices, on our website at or by calling the USCIS toll-free forms line at

Part 5. Signature. Read the information on penalties in the instructions before completing this section. If someone helped you prepare this petition, he or she must complete Part 6.

YOUR CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Copies of documents submitted are exact photocopies of unaltered original documents and I understand that I may be required to submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from my records that the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit that I am seeking.

Signature _______________________________

Daytime Phone Number (Area/Country Codes) _______________________________

Date (mm/dd/yyyy) _______________________________

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible for the requested benefit and this petition may be denied.

Part 6. Signature of person preparing form if other than above.

I declare that I prepared this application at the request of the applicant and it is based on all information of which I have knowledge.

Attorney or Representative: In the event of a Request for Evidence (RFE) may USCIS contact you by Fax or E-mail?

____ Yes ____ No

Signature _______________________________

Print Your Name _______________________________

Date (mm/dd/yyyy) _______________________________

Firm Name and Address _______________________________

Daytime Telephone Number (Area/Country Codes) _______________________________

Fax Number (Area/Country Codes) _______________________________

E-Mail Address _______________________________

Part 7. Checklist.

____ Did you answer each question?

____ Did you sign the Form I-821 application?

____ Did you submit the required application and biometric services (fingerprinting) fees?

____ Did you submit the necessary documents and photos, if so required?

____ Did you also submit the Form I-765 with the filing fee or a written request for a waiver of the filing fee (See instructions, items 10, 11 and 12)?

Have you submitted:

____ The filing fee for this application or a written request for a waiver of the filing fee (see instructions, items10 and 12)?

____ Supporting evidence to prove identity, nationality, date of entry and residence?

____ Other required supporting documents (photos, etc.) for each application?

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