I 821 Form – Fill Out and Use This PDF

Application for Temporary Protected Status

USCIS

Form I-821

Department of Homeland Security

U.S. Citizenship and Immigration Services

OMB No. 1615-0043 Expires 07/31/2022

Receipt

Remarks

Action Block

Case ID:

A-Number:

Returned:

Resubmitted:

Relocated:

Received:

Sent:

►START HERE - Type or print in black ink.

Part 1. Type of Application (select one)

NOTE: Select the box for Item Number 1.a., 1.b., or 2. If applicable, select the box for Item Number 3.a. or 3.b. For Item Number 4., enter the name of the designated TPS country.

Are you also filing a request for employment authorization? 3.a.

1.a. This is my initial (first time) application for Temporary Protected Status (TPS). I do not currently have TPS.

1.b. This is my re-registration application for TPS. I currently have TPS, and am applying to re-register.

NOTE: If you have previously applied or have a pending application for TPS, but do not currently have TPS, select Item Number 1.a. and describe each time that you previously applied, including the receipt number (if available) and the outcome (if any) of each application. If you currently have a pending TPS application, please also describe when you filed it and the application receipt number (if available) in Part 11. Additional Information. If you do not recall or have incomplete information on your prior TPS applications, please provide the information you can, even if incomplete.

2.If you selected Item Number 1.b., please indicate who granted you TPS.

USCIS

Immigration Judge/Board of Immigration Appeals

3.b.

4.Name of designated TPS country under which you are applying.

Part 2. Information About You

Your Full Name

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

Part 2. Information About You (continued)

Other Names Used

Provide all other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

U.S. Mailing Address

4.a. In Care Of Name

4.b. Street Number

and Name

4.c. Apt. Ste. Flr.

4.d. City or Town

4.e. State		4.f. ZIP Code

5.Is your current mailing address the same as your physical

address (where you live)?	Yes	No

If you answered "No" to Item Number 5., please provide your physical address below.

U.S. Physical Address

6.a. Street Number

and Name

6.b. Apt. Ste. Flr.

6.c. City or Town

6.d. State		6.e. ZIP Code

Other Information

7.Alien Registration Number (A-Number) (if any)

► A-

8.USCIS Online Account Number (if any)

►

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

►

10. Date of Birth (mm/dd/yyyy)

Other Dates of Birth Used (if any)

Provide all other dates of birth you have ever used. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

11.a. Other Date of Birth (mm/dd/yyyy)

11.b. Other Date of Birth (mm/dd/yyyy)

12. Gender

Male

Female

13.City/Town/Village of Birth

14.Country of Birth

Countries of Residence (Before entering the U.S.)

15.a.

15.b.

15.c.

15.d.

Country or Countries of Citizenship or Nationality (if any) (List all countries that apply.)

16.a.

16.b.

16.c.

16.d.

Your Marital Information

17.Current Marital Status (Select only one box)

Single, Never Married		Married
Divorced		Widowed
Separated		Marriage Annulled
Other

Part 2. Information About You (continued)

18.Date of Current Marriage (if currently married)

(mm/dd/yyyy)

U.S. Entry Information

19.Date of Last Entry into the United States

(mm/dd/yyyy)

20.Immigration Status (or Lack of Status) When You Last Entered the United States (for example, visitor, student, no status)

Place of Last Entry into the United States

21.U.S. Port of Entry (if any)

22.a. City or Town

22.b. State

23.Form I-94 Arrival-Departure Record Number (if any)

►

24.Date Your Authorized Period of Stay in the United States Expired or Will Expire (as shown on Form I-94 or Crewman's Landing Permit (Form I-95)) (mm/dd/yyyy or

duration of status (D/S)

25.Passport Number (most recent passport) (if any) (If you have other expired or valid passports, please list all of them and provide all information requested below about each passport.)

26.Travel Document Number (if any)

27.Additional Passport or Travel Document Number

28.Additional Passport or Travel Document Number

29.Country of Issuance for most recent Passport or Travel Document

30.Expiration Date for most recent Passport or Travel

Document (mm/dd/yyyy)

Your Current Immigration Status

31.Current Immigration Status or Lack of Status

32.Are you now or were you EVER in immigration

proceedings?	Yes	No

If you answered "Yes" to Item Number 32., provide the following information.

Type of Proceedings (Select all boxes that apply):

33.a.	Immigration Court (before an Immigration Judge)
33.b.	Board of Immigration Appeals (BIA)
33.c.	I am no longer in Department of Justice (DOJ) or
	Department of Homeland Security (DHS)
	immigration proceedings, but I am or was in Federal
	court proceedings regarding immigration issues.

34.Locations Where Your DOJ and/or DHS Proceedings were Held (or are currently being held) (if applicable)

35.Locations Where Your Federal Court Proceedings Regarding Immigration Issues were Held (or are currently being held) (if applicable)

Dates for Your Proceedings

NOTE: If your proceedings are ongoing, leave the “To” date blank. If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period.

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

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

36.c. Present

Part 3. Biographic Information

1.Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino

2.Race (Select all applicable boxes)

White

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Part 3. Biographic Information (continued)

3.	Height	Feet		Inches
4.	Weight		Pounds

5.Eye Color (Select only one box)

Mailing Address of Spouse

4.a. Street Number

and Name

4.b. Apt. Ste. Flr.

4.c. City or Town

Black	Blue	Brown
Gray	Green	Hazel
Maroon	Pink

Unknown/Other

6.Hair Color (Select only one box)

4.d. State

4.f. Province

4.g. Postal Code 4.h. Country

4.e. ZIP Code

Bald (No hair)	Black	Blond
Brown	Gray	Red
Sandy	White
Unknown/Other

Part 4. Information About Your Current Spouse

(if any)

Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses and all of your children, please use the space provided in Part 11. Additional Information.

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

1.USCIS Online Account Number (if any and if known)

►

2.A-Number (if any and if known)

► A-

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

Other Information About Your Current Spouse

5.Your Spouse's Date of Birth (mm/dd/yyyy)

6.Date of Marriage to Your Current Spouse

(mm/dd/yyyy)

7.Place of Marriage to Your Current Spouse

8.a. City or Town

8.b. State

8.c. Province (if any) 8.d. Country

9.If you know, has your current spouse EVER had TPS?

Yes

No

If yes, what dates did he or she have TPS?

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

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

10.c.	Present
10.d.	I do not know the dates

11.Is your spouse's TPS still valid? (if known)

Yes

No

I Do Not Know

Part 5. Information About Your Former Spouses (if any)

Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses or all of your children, please use the space provided in Part 11. Additional Information.

Names of All Your Former Spouses (if any)

First Marriage

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2.Nationalities of Former Spouse

3.A-Number of Former Spouse (if any and if known)

► A-

4.Date of Birth of Former Spouse (mm/dd/yyyy)

5.Date of Death if Former Spouse Deceased

(mm/dd/yyyy)

Dates of Marriage to Former Spouse

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

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

7.How Marriage Ended (for example, divorce, widowed, annulled)

8.Did or does this former spouse have TPS (if known)?

Yes

No

I Do Not Know

If yes, what dates did he or she have TPS (if known)?

9.a.	From (mm/dd/yyyy)
9.b.	To (mm/dd/yyyy)
9.c.	Present
9.d.	I do not know the dates

10.Is this former spouse currently applying for or re- registering for TPS (if known)?

Yes

No

I Do Not Know

Second Marriage

11.a. Family Name

(Last Name)

11.b. Given Name

(First Name)

11.c. Middle Name

12.Nationalities of Former Spouse

13.A-Number of Former Spouse (if any and if known)

A-

14.Date of Birth of Former Spouse (mm/dd/yyyy)

15.Date of Death if Former Spouse Deceased

(mm/dd/yyyy)

Dates of Marriage to Former Spouse

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

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

17.How Marriage Ended (for example, divorce, widowed, annulled)

18.Did or does this former spouse have TPS (if known)?

Yes

No

I Do Not Know

If yes, what dates did he or she have TPS (if known)?

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

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

19.c.	Present
19.d.	I do not know the dates

20.Is this former spouse currently applying for or re- registering for TPS (if known)?

Yes

No

I Do Not Know