I 821D – Fill Out and Use

A-

For

USCIS Case ID:

Use

Only Requestor interviewed on

Receipt

/ /

Action Block

To Be Completed by an Attorney or Accredited Representative, if any.

Select this box if Form G-28 is attached to represent the requestor.

Attorney State Bar Number (if any):

Part 1. Information About You (For Initial and

Renewal Requests)

I am not in immigration detention and I have included Form I-765, Application for Employment Authorization, and Form I-765WS, Form I-765 Worksheet; and

I am requesting:

1. Initial Request - Consideration of Deferred Action for Childhood Arrivals

OR

2. Renewal Request - Consideration of Deferred Action for Childhood Arrivals

AND

For this Renewal request, my most recent period of Deferred Action for Childhood Arrivals expires on

(mm/dd/yyyy) ►

Full Legal Name

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

U.S. Mailing Address (Enter the same address on Form I-765)

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

4.b. Street Number

and Name

Removal Proceedings Information

5.Are you NOW or have you EVER been in removal proceedings, or do you have a removal order issued in any other context (for example, at the border or within the United States by an immigration agent)?

Yes No

NOTE: The term “removal proceedings” includes exclusion or deportation proceedings initiated before April 1, 1997; an Immigration and Nationality Act (INA) section 240 removal proceeding; expedited removal; reinstatement of a final order of exclusion, deportation, or removal; an INA section 217 removal after admission under the Visa Waiver Program; or removal as a criminal alien under INA section 238.

If you answered "Yes" to Item Number 5., you must select a box below indicating your current status or outcome of your removal proceedings.

Status or outcome:

5.f. Most Recent Date of Proceedings

(mm/dd/yyyy) ►

5.g. Location of Proceedings

4.e. State

4.f. ZIP Code

Part 1. Information About You (For Initial and

Renewal Requests) (continued)

Other Information

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

► A-

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

►

8.Date of Birth (mm/dd/yyyy) ►

10.b. Country of Birth

11.Current Country of Residence

12.Country of Citizenship or Nationality

13.Marital Status

Married Widowed Single Divorced

Other Names Used (If Applicable)

If you need additional space, use Part 8. Additional

Information.

14.a. Family Name

(Last Name)

14.b. Given Name

(First Name)

14.c. Middle Name

Processing Information

15.Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino

16.Race (Select all applicable boxes)

White

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

19.Eye Color (Select only one box)

20.Hair Color (Select only one box)

Part 2. Residence and Travel Information (For

Initial and Renewal Requests)

1.I have been continuously residing in the U.S. since at least

NOTE: If you departed the United States for some period of time before your 16th birthday and returned to the United States on or after your 16th birthday to begin your current period of continuous residence, and if this is an initial request, submit evidence that you established residence in the United States prior to 16 years of age as set forth in the instructions to this form.

For Initial Requests: List your current address and, to the best of your knowledge, the addresses where you resided since the date of your initial entry into the United States to present.

For Renewal Requests: List only the addresses where you resided since you submitted your last Form I-821D that was approved.

If you require additional space, use Part 8. Additional

Information.

Part 2. Residence and Travel Information (For

Initial and Renewal Requests) (continued)

Present Address

2.a. Dates at this residence (mm/dd/yyyy)

Travel Information

For Initial Requests: List all of your absences from the United States since June 15, 2007.

For Renewal Requests: List only your absences from the United States since you submitted your last Form I-821D that was approved.

If you require additional space, use Part 8. Additional

Information.

Departure 1

8.Have you left the United States without advance parole on

10.Border Crossing Card Number (if any)

Part 3. For Initial Requests Only

1.I initially arrived and established residence in the U.S.

2.Date of Initial Entry into the United States (on or about)

(mm/dd/yyyy) ►

3.Place of Initial Entry into the United States

Part 3. For Initial Requests Only (continued)

4.Immigration Status on June 15, 2012 (e.g., No Lawful Status, Status Expired, Parole Expired)

5.b. If you answered "Yes" to Item Number 5.a., provide your Form I-94, I-94W, or I-95 number (if available).

►

5.c. If you answered "Yes" to Item Number 5.a., provide the date your authorized stay expired, as shown on Form I-94, I-94W, or I-95 (if available).

(mm/dd/yyyy) ►

Education Information

6.Indicate how you meet the education guideline (e.g., Graduated from high school, Received a general educational development (GED) certificate or equivalent state-authorized exam, Currently in school)

7.Name, City, and State of School Currently Attending or Where Education Received

8.Date of Graduation (e.g., Receipt of a Certificate of Completion, GED certificate, other equivalent state- authorized exam) or, if currently in school, date of last

attendance. (mm/dd/yyyy) ►

Military Service Information

9.Were you a member of the U.S. Armed Forces or U.S.

If you answered "Yes" to Item Number 9., you must provide responses to Item Numbers 9.a. - 9.d.

9.a. Military Branch

Part 4. Criminal, National Security, and Public

Safety Information (For Initial and Renewal Requests)

If any of the following questions apply to you, use Part 8. Additional Information to describe the circumstances and include a full explanation.

1.Have you EVER been arrested for, charged with, or convicted of a felony or misdemeanor, including incidents handled in juvenile court, in the United States? Do not include minor traffic violations unless they were alcohol-

If you answered “Yes,” you must include a certified court disposition, arrest record, charging document, sentencing record, etc., for each arrest, unless disclosure is prohibited under state law.

2.Have you EVER been arrested for, charged with, or convicted of a crime in any country other than the United

If you answered "Yes," you must include a certified court disposition, arrest record, charging document, sentencing record, etc., for each arrest.

3.Have you EVER engaged in, do you continue to engage in, or plan to engage in terrorist activities?

Yes No

4.Are you NOW or have you EVER been a member of a

5.Have you EVER engaged in, ordered, incited, assisted, or otherwise participated in any of the following:

5.a. Acts involving torture, genocide, or human trafficking?

6.Have you EVER recruited, enlisted, conscripted, or used any person to serve in or help an armed force or group

7.Have you EVER used any person under age 15 to take part in hostilities, or to help or provide services to people

Part 5. Statement, Certification, Signature, and Contact Information of the Requestor (For Initial

and Renewal Requests)

NOTE: Select the box for either Item Number 1.a. or 1.b.

1.a. I can read and understand English, and have read and understand each and every question and instruction on this form, as well as my answer to each question.

1.b. The interpreter named in Part 6. has read to me each and every question and instruction on this form, as well as my answer to each question, in

, a language in which I am fluent. I understand each and every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above.

Requestor's Certification

I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct and that copies of documents submitted are exact photocopies of unaltered original documents. I understand that I may be required to submit original documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. I also understand that knowingly and willfully providing materially false information on this form is a federal felony punishable by a fine, imprisonment up to 5 years, or both, under 18 U.S.C. section 1001. Furthermore, I authorize the release of any information from my records that USCIS may need to reach a determination on my deferred action request.

2.a. Requestor's Signature

2.b. Date of Signature (mm/dd/yyyy) ►

Requestor's Contact Information

3.Requestor's Daytime Telephone Number

4.Requestor's Mobile Telephone Number

5.Requestor's Email Address

Part 6. Contact Information, Certification, and Signature of the Interpreter (For Initial and

Renewal Requests)

Interpreter's Full Name

Provide the following information concerning the interpreter: 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)

Interpreter's Mailing Address

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Email Address

Part 6. Contact Information, Certification, and

Signature of the Interpreter (For Initial and

Renewal Requests) (continued)

Interpreter's Certification

is the same language provided in Part 5., Item Number 1.b.;

I have read to this requestor each and every question and instruction on this form, as well as the answer to each question, in the language provided in Part 5., Item Number 1.b.; and

The requestor has informed me that he or she understands each and every instruction and question on the form, as well as the answer to each question.

6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy) ►

Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, If Other than the Requestor (For Initial and

Renewal Requests)

Preparer's Full Name

Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name)

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

2.Preparer's Business or Organization Name

Preparer's Mailing Address

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Fax Number

6.Preparer's Email Address

Preparer's Declaration

I declare that I prepared this Form I-821D at the requestor's behest, and it is based on all the information of which I have knowledge.

7.a. Preparer's Signature

7.b. Date of Signature (mm/dd/yyyy) ►

NOTE: If you need extra space to complete any item within this request, see the next page for Part 8. Additional

Information.

Part 8. Additional Information (For Initial and

Renewal Requests)

If you need extra space to complete any item within this request, use the space below. You may also make copies of this page to complete and file with this request. Include your name and A-Number (if any) at the top of each sheet of paper; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

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

4.d.