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

Part 6. Information About Your Children

(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.

Provide the following information about each of your children (if any). If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

Child 1

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

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

►

3.	Alien Registration Number (A-Number) (if any and if
	known)

Child 2

8.a. Family Name

(Last Name)

8.b. Given Name

(First Name)

8.c. Middle Name

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

►

10.Alien Registration Number (A-Number) (if any and if known)

►A-

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

Mailing Address

12.a. Street Number

and Name

12.b.	Apt.	Ste.		Flr.
12.c.	City or Town

► A-

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

Mailing Address

5.a. Street Number

and Name

12.d. State

12.f. Province

12.g. Postal Code 12.h. Country

12.e. ZIP Code

5.b. Apt. Ste. Flr. 5.c. City or Town

If this child has or had TPS, please provide the dates of his or her TPS (if known).

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

5.d. State

5.f. Province

5.g. Postal Code 5.h. Country

5.e. ZIP Code

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

14.If you know, is this child currently applying for or re-

registering for TPS (if known)?	Yes	No

Part 7. Eligibility Standards

If this child has or had TPS, please provide the dates of his or her TPS (if known).

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

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

7.If you know, is this child currently applying for or re-

registering for TPS (if known)?

Yes

No

Basis for Eligibility

Provide the following information:

1.a. I am a national of (or a person having no nationality who last habitually resided in the country of):

Part 7. Eligibility Standards) (continued)

1.b. I entered the United States on the following date, and have resided in the United States since that time.

(mm/dd/yyyy)

1.c. Have you EVER traveled to and entered another country, other than the one listed in Item Number 1.a. before you

last entered the United States?	Yes	No

If you answered "Yes" to Item Number 1.c., provide the information requested in Item Numbers 2. - 5. for EACH country you traveled to and entered prior to entering the United States. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

2.Name of All the Other Countries to Which You Traveled and Entered Prior to Entering the United States

Dates That You Were in the Other Country or Countries

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

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

4.Your Immigration Status, if Any, in the Other Country (for example, citizen, legal permanent resident, refugee, asylee, visitor, student, temporary resident, or no status)

5.Have you EVER been offered any immigration status by another country that you did not accept?

Yes

No

6.If you answered "Yes" to Item Number 5., please describe the country or countries, the nature of the immigration status you were offered, and the dates when it was offered.

7.If you answered “Yes” to Item Number 5., please describe why you chose not to accept the immigration status offered to you by the other country or countries.

Your Immigration and Criminal History

To be eligible for TPS, you must be admissible as an immigrant to the United States, with certain exceptions. The questions below and your responses to these questions will help USCIS determine if you are eligible for TPS. See the Who Is Eligible for TPS section of the Instructions for additional information on admissibility and available waivers.

If any of the questions apply to you, please provide information about the events, including the places and dates of occurrence. Provide a full explanation of the circumstances related to the specific event. If you need additional space to respond to a question, use the space provided in Part 11. Additional

Information.

Criminal Offenses

If you were EVER arrested or detained for an offense, you must provide information about the event regardless of the country where the event occurred. If you were arrested, charged, or convicted for an offense, you must provide certified court dispositions showing the court proceedings' outcome wherever possible. You also must provide copies of arrest reports, statements of charges, indictment information, or any other charging document issued against you. If you were not charged with any crime or offense, provide a statement or other documentation from the arresting authority or prosecutor's office to show that you were not charged with any crime or offense.

NOTE: If you are not able to provide the documentation requested above, provide a signed statement as to why you cannot provide such documentation. USCIS usually needs supporting documentation, however, we do recognize that country conditions in certain TPS-designated countries may not allow an applicant to obtain the documents. Each statement will be carefully reviewed by USCIS, and we may need to ask you for additional information.

Please carefully read Item 6. in the General Requirements section of the Instructions for additional information that you must provide if official documents regarding your criminal history are not available to you.

Human Rights Violations

If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred.

Have you EVER been convicted of:

8.a. Any felony committed in the United States?

Yes

No

8.b. Any misdemeanor committed in the United States?

Yes

No

Part 7. Eligibility Standards (continued)

8.c. Any particularly serious crime committed either in or

outside the United States?	Yes	No

9.a. Have you EVER 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

9.b. Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the

United States?	Yes	No

9.c. Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States?

Yes

No

Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of:

10.a. A crime (other than a purely political offense)?

Yes

No

10.b. A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances

Act?	Yes	No

10.c. A conspiracy to violate any law relating to a controlled

substance as defined in section 102 of the Controlled
Substances Act?	Yes	No

11.Have you EVER been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when

combined, total five years or more?	Yes	No

12.a. Have you EVER trafficked in or are you NOW trafficking in any controlled substance?

Yes

No

12.b. Are you NOW or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance?

Yes

No

12.c. Are you the spouse or child of an alien who unlawfully trafficked in any controlled substance?

Yes

No

12.d. Are you the spouse or child of an alien who assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance?

Yes

No

12.e. Within the previous five years, have you EVER obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit

activity?	Yes	No

Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following:

13.a. Any activity to violate any law of the United States
relating to espionage or sabotage?	Yes	No

13.b. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or

sensitive information?	Yes	No

13.c. Any other unlawful activity in the United States?

Yes

No

13.d. Any activity in which a purpose is to oppose, control, or overthrow the Government of the United States by force, violence, or other unlawful means, including but not limited to participating in such activities, giving support to others involved in such activities, or being a member or representative of a terrorist organization?

Yes

No

14.a. Have you EVER or are you NOW engaged in terrorist

activities?	Yes	No

14.b. Have you EVER or are you NOW engaged 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

14.c. Have you EVER been or are you NOW a member of the

Communist or other totalitarian party, except when
membership was involuntary?	Yes	No
14.d. Have you EVER participated in Nazi persecution or
genocide?	Yes	No

Have you EVER, whether in the United States or any other country been:

15.a. Arrested, for breaking or violating any law or ordinance,

excluding minor traffic violations?	Yes	No

15.b. Cited, charged, or indicted, for breaking or violating any law or ordinance, excluding minor traffic violations?

Yes

No

15.c. Been convicted, fined, imprisoned, placed on probation, received a suspended sentence or deferral of adjudication for breaking or violating any law or ordinance, excluding

minor traffic violations?	Yes	No

Part 7. Eligibility Standards (continued)

16.Have you EVER been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or

similar action?	Yes	No

17.Have you EVER committed a serious criminal offense in the United States and asserted immunity from

prosecution?	Yes	No

18.a. Have you EVER, within the past 10 years, or are you

NOW engaged in prostitution or procurement of
prostitution?	Yes	No

18.b. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution?

Yes

No

18.c. Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution?

Yes

No

19.Have you EVER been or do you intend to be involved in

any other commercial vice?	Yes	No
20.a. Have you EVER been ordered removed, and been
deported from the United States?	Yes	No

20.b. Have you EVER voluntarily departed the United States

under an order of removal?	Yes	No

20.c. If you answered "Yes" to either Item Number 20.a. or 20.b. above, have you re-entered the United States unlawfully at any time after you were deported or you

voluntarily departed?	Yes	No

20.d. If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal?

Yes

No

I Do Not Know

20.e. Have you EVER failed to attend or remain in attendance

at any immigration proceedings to determine your
admissibility or deportability?	Yes	No

21.Have you EVER, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other documentation, admission to the United States, or any

other immigration benefit?	Yes	No

22.Have you EVER assisted any other person to enter the

United States in violation of the law?	Yes	No

23.a. Do you NOW have a communicable disease of public

health significance?	Yes	No

23.b. Do you NOW have or have you EVER 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?	Yes	No

23.c. Are you NOW or have you EVER been a drug abuser or

drug addict?	Yes	No

24.Have you EVER entered the United States as a

stowaway?	Yes	No

25.Did the former Immigration and Naturalization Service (INS) EVER impose, or has DHS EVER imposed, civil monetary penalties on you for producing or using false documentation to obtain an immigration benefit?

Yes

No

26.Are you NOW 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)?	Yes	No
27. Do you NOW practice polygamy?	Yes	No

28.Are you NOW the guardian of, and are you accompanying, another individual who has been found to be inadmissible and who has been certified by a medical examiner to be helpless due to sickness, physical or

mental disability, or infancy?	Yes	No

29.Have you EVER detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from a U.S. citizen

granted custody?	Yes	No

Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:

30.a. Acts involving torture or genocide?	Yes	No
30.b. Killing any person?	Yes	No
30.c. Intentionally and severely injuring any person?
	Yes	No

30.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?

	Yes	No
30.e. Limiting or denying any person's ability to exercise
religious beliefs?	Yes	No

Part 7. Eligibility Standards (continued)

Have you EVER:

31.a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self- defense unit, vigilante unit, rebel group, guerrilla group,

militia, or insurgent organization?	Yes	No

31.b. Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that

involved detaining persons?	Yes	No

32.Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?

Yes

No

33.Have you EVER assisted with or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them

against another person?	Yes	No

34.Have you EVER received any type of military,

paramilitary, or weapons training?	Yes	No

35.Have you EVER unlawfully voted in a United States

Federal, state, or local election?	Yes	No

36.Have you EVER claimed to be a U. S. citizen (in writing

or in any other way)?	Yes	No

37.a. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an

armed force or group?	Yes	No

37.b. Have you EVER used any person under 15 years of age to take part in hostilities or to help or provide services to

people in combat?	Yes	No

38.a. Have you EVER committed or conspired to commit human trafficking offenses, as defined in the section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States?

Yes

No

38.b. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker?

	Yes	No
38.c. Are you NOW the spouse or child of an alien who
committed or conspired to commit human trafficking
offenses?	Yes	No

38.d. Are you NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker?

Yes

No

38.e. Within the previous five years, have you EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking?

Yes

No

39.a. Are you NOW or have you EVER engaged in money laundering as described in section 1956 or 1957 of Title

18, United States Code?	Yes	No

39.b. Are you NOW or have you EVER been a knowing aider, abettor, assister, conspirator, or colluder with others in

money laundering?	Yes	No

40.Have you EVER been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998 (22 U.S.C. section 6402) while serving as a foreign government official?

Yes

No

41.Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous

asylum application in the past?	Yes	No

Part 8. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form I-821 Instructions before completing this part. You must file Form I-821 while in the United States.

Applicant's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question.

1.b. The interpreter named in Part 9. read to me every question and instruction on this application and my

answer to every question in

a language in which I am fluent, and I understood everything.

2. At my request, the preparer named in Part 10.,

prepared this application for me based only upon information I provided or authorized.

Part 8. Applicant's Statement, Contact Information, Certification, and Signature

(continued)

Applicant's Contact Information

3.Applicant's Daytime Telephone Number

4.Applicant's Mobile Telephone Number (if any)

5.Applicant's Email Address (if any)

Part 9. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

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

2.Interpreter's Business or Organization Name (if any)

Applicant's 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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws.

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, I will be required to sign an oath reaffirming that:

1)I reviewed and provided or authorized all of the information in my application;

2)I understood all of the information contained in, and submitted with, my application; and

3)All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.

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

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (if any)

Applicant's Signature

6.a. Applicant's Signature

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

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and		,

which is the same language specified in Part 8., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer.

Part 9. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Signature

7.a. Interpreter's Signature

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

Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

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

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

Preparer's Statement

7.a.	I am not an attorney or accredited representative but
	have prepared this application on behalf of the
	applicant and with the applicant's consent.
7.b.	I am an attorney or accredited representative and my
	representation of the applicant in this case
	extends	does not extend beyond the

preparation of this application.

NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Certification, and that all of this information is complete, true and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Preparer's Signature

8.a. Preparer's Signature

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

3.d. State

3.f. Province

3.g. Postal Code 3.h. Country

3.e. ZIP Code

Part 11. 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.

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.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.