Official Federal Forms > US Citizenship And Immigration Services
Application For Temporary Protected Status I-821 - Official Federal Forms
| Application For Temporary Protected Status Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0043; Exp. 10/31/2013 Department of Homeland Security U.S. Citizenship and Immigration Services I-821, Application for Temporary Protected Status For USCIS Use Only Returned Date Date Resubmitted Date Date Reloc Sent Date State Zip Code Gender Male Female State/Country Country of Citizenship/Nationality Date Reloc Rec'd Date Date Applicant Interviewed on Case ID #: A #: Widowed Remarks Receipt START HERE - Please type or print in black ink. Part 1. Type of application (check one) a. b. This is my first application to register for Temporary Protected Status (TPS). 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 Given Name (First Name) Full Middle Name Apt. # Family Name (Last Name) U.S. Mailing Address: (Street Number and Name) C/O: (In Care Of) Town/City County Date of Birth (mm/dd/yyyy) Place of Birth (Town or City) Country of Residence Marital Status Single Married Divorced 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) Number Your Current Immigration Status: In Status (state nonimmigrant classification, e.g., F-1, etc.) Date authorized stay expired/or will expire, as shown on Form I-94 or I-95 (mm/dd/yyyy) Action Block Out of Status (state nonimmigrant violation, e.g., overstay student, EWI etc.) U.S. Social Security Number (if any) Alien Registration Number (A#) (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. Type of proceedings: Exclusion Removal/Deportation Recission Judicial Proceedings Location of Proceedings Date of Proceedings (mm/dd/yyyy) To Be Completed by Attorney or Representative, if any. Fill in box if G-28 is attached to represent the applicant. ATTY State License # Form I-821 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information about your spouse and children (if any) Middle Name Apt # Country Date and Place of Present Marriage Date(s) Marriage(s) Ended (mm/dd/yyyy) Zip/Postal Code 1. Provide the following information about your spouse (if married). Last Name of Spouse First Name Address (Street Number and Name) Town/City State/Province Your Spouse's Birth Date (mm/dd/yyyy) Name of Prior Husbands/Wives 2. List the names, ages, and current residence of children (if any). Name (First/Middle/Last) Date of Birth (mm/dd/yyyy Residence Part 4. Eligibility standards 1. Provide the following information: I am a national of (or an alien having no nationality, who last habitually resided in the 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. 2. 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 Pages 3, 4, and 5 apply to you, describe the circumstances 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) for all arrests. For example, "case dismissed" from the appropriate authority. NOTE: For information about waivers concerning the grounds of inadmissibility, see Page 5. 2a. Have you been convicted of any felony or two or more misdemeanors committed in the United States? Yes No 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? Yes No (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)? Yes Yes No No Form I-821 (Rev. 11/23/10) Y Page 2 (iii) Have you committed a serious nonpolitical crime outside of the United States prior to your arrival in the United States? American LegalNet, Inc. www.FormsWorkFlow.com (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? Yes No 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? Yes No (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? Yes No (iii) Have you trafficked in or do you continue to traffic in any controlled substance, or are you or have you been a knowing assister, abettor, conspirator, or colluder with others in the illicit trafficking of any controlled substance? Yes No (iv) Have you engaged in 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? Yes No (v) Have you engaged in or do you continue to engage in terrorist activities? Yes No (vi) Have you engaged in or do you continue to engage in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States? Yes No (vii) Have you been or do you continue to be a member of the Communist or other totalitarian party, except when membership was involuntary? Yes No (viii) Have you participated in Nazi persecution or genocide? Yes No 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 decr
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