Form I-821 Edition 04/01/24 Page 1 of 13

Application for Temporary Protected Status 

Department of Homeland Security 

U.S. Citizenship and Immigration Services 

USCIS 

Form I-821 

OMB No. 1615-0043 

Expires 02/28/2027

For USCIS Use Only

Remarks

Receipt

Resubmitted:

Returned:

Sent:

Received:

Case ID:

A-Number:

Relocated:

Action Block

To be completed 

by an Attorney 

or Accredited 

Representative (if any).

Select this box if 

Form G-28 or 

G-28I is 

attached.

Attorney State Bar Number 

(if applicable)

Attorney or Accredited Representative 

USCIS Online Account Number (if any)

► 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.

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. 

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

granted you TPS. 

USCIS 

Immigration Judge/Board of Immigration Appeals

Are you also filing a request for employment authorization?

3.a. Yes, I am requesting an Employment Authorization 

Document (EAD), and I am filing Form I-765, 

Application for Employment Authorization, together 

with my Form I-821.

3.b. No, I am not currently requesting an EAD.

Part 2. Information About You

Your Full Name 

1.a. Family Name 

(Last Name) 

1.b. Given Name 

(First Name) 

1.c. Middle Name

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.

Name of designated TPS country under which you are 

applying.

4.
Form I-821 Edition 04/01/24 Page 2 of 13

3.a. Family Name 

(Last Name) 

3.b. Given Name 

(First Name) 

3.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

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)

► A8. 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

11.b. Other Date of Birth

(mm/dd/yyyy)

(mm/dd/yyyy)

12. Gender Male Female

13. City/Town/Village of Birth

14. Country of Birth

17. Current Marital Status (Select only one box)

Single, Never Married Married

Divorced Widowed

Separated Marriage Annulled

Other

Your Marital Information

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

Country or Countries of Citizenship or Nationality (if any) 

(List all countries that apply.)

15.a.

15.b.

15.c.

15.d.

16.a.

16.b.

16.c.

16.d.

(USPS ZIP Code Lookup)
Form I-821 Edition 04/01/24 Page 3 of 13

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.)

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)

26. Travel Document Number (if any)

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 

From (mm/dd/yyyy)

To (mm/dd/yyyy)

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.

36.b.

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

36.c. Present
Form I-821 Edition 04/01/24 Page 4 of 13

Part 3. Biographic Information (continued)

5. Eye Color (Select only one box)

Black Blue Brown

Gray Green Hazel

Maroon Pink

Unknown/Other

6. Hair Color (Select only one box)

Bald (No hair) Black Blond

Brown Gray Red

Sandy White

Unknown/Other

3. Height Feet Inches

4. Weight Pounds

Part 4. Information About Your Current Spouse 

(if any)

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)

► AComplete 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.

3.a. Family Name 

(Last Name) 

3.b. Given Name 

(First Name) 

3.c. Middle Name

Mailing Address of Spouse 

4.a. Street Number 

and Name

4.b. Apt. Ste. Flr.

4.c. City or Town

4.d. State 4.e. ZIP Code

4.f. Province 

4.g. Postal Code 

4.h. Country 

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.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?

From (mm/dd/yyyy)

To (mm/dd/yyyy)

10.a.

10.b.

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

8.b. State
Form I-821 Edition 04/01/24 Page 5 of 13

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)

► A4. 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 

From (mm/dd/yyyy)

To (mm/dd/yyyy)

6.a.

6.b.

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

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

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

annulled)

Yes No I Do Not Know

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 reregistering 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)

A14. 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 

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

annulled)

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

From (mm/dd/yyyy)

To (mm/dd/yyyy)

16.a.

16.b.

Yes No I Do Not Know

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

20. Is this former spouse currently applying for or reregistering for 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

Yes No I Do Not Know
Form I-821 Edition 04/01/24 Page 6 of 13

Part 6. Information About Your Children 

(if any)

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)

► A4. Date of Birth (mm/dd/yyyy)

Mailing Address

5.a. Street Number 

and Name

5.b. Apt. Ste. Flr.

5.c. City or Town

5.d. State 5.e. ZIP Code

5.f. Province 

5.g. Postal Code 

5.h. Country 

If this child has or had TPS, please provide the dates of his or 

her TPS (if known).

From (mm/dd/yyyy)

To (mm/dd/yyyy)

7. If you know, is this child currently applying for or reregistering for TPS (if known)? Yes No

6.a.

6.b.

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.

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)

► A11. Date of Birth (mm/dd/yyyy)

Mailing Address

12.a. Street Number 

and Name

12.b. Apt. Ste. Flr.

12.c. City or Town

12.d. State 12.e. ZIP Code

12.f. Province 

12.g. Postal Code 

12.h. Country 

If this child has or had TPS, please provide the dates of his or 

her TPS (if known).

14. If you know, is this child currently applying for or reregistering for TPS (if known)? Yes No

From (mm/dd/yyyy)

To (mm/dd/yyyy)

13.a.

13.b.

Part 7. Eligibility Standards

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):
Form I-821 Edition 04/01/24 Page 7 of 13

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

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

From (mm/dd/yyyy)

To (mm/dd/yyyy)

3.a.

3.b.

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.

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

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.
Form I-821 Edition 04/01/24 Page 8 of 13

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:

Any activity to violate any law of the United States 

relating to espionage or sabotage?

13.a.

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

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

excluding minor traffic violations? Yes No

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

country been:

Yes

Cited, charged, or indicted, for breaking or violating any 

law or ordinance, excluding minor traffic violations?

No

15.b.

Yes

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? No

15.c.
Form I-821 Edition 04/01/24 Page 9 of 13

Part 7. Eligibility Standards (continued)

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

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

at any immigration proceedings to determine your 

admissibility or deportability? Yes No

I Do Not Know

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

18.c. Have you EVER, within the past 10 years, received, in 

whole or in part, the proceeds of prostitution?

Yes No

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?

18.b. 

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

Have you EVER been the beneficiary of a pardon, 

amnesty, rehabilitation decree, other act of clemency, or 

similar action?

16.

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
Form I-821 Edition 04/01/24 Page 10 of 13

Part 7. Eligibility Standards (continued)

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.

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

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.

prepared this application for me based only upon 

information I provided or authorized.

Have you EVER:

31.a. Served in, been a member of, assisted in, or participated 

in any military unit, paramilitary unit, police unit, selfdefense 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
Form I-821 Edition 04/01/24 Page 11 of 13

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:

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.

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. 

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)

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 

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 Contact Information

4. Interpreter's Daytime Telephone Number

6. Interpreter's Email Address (if any)

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

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)

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.
Form I-821 Edition 04/01/24 Page 12 of 13

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

3.d. State 3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country 

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)

Part 9. Interpreter's Contact Information, 

Certification, and Signature (continued)

Preparer's Contact Information

4. Preparer's Daytime Telephone Number

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

6. Preparer's Email Address (if any)
Form I-821 Edition 04/01/24 Page 13 of 13

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.

Part 11. Additional Information

1.a. Family Name 

(Last Name) 

1.b. Given Name 

(First Name) 

1.c. Middle Name

2. A-Number (if any) ►A3.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.