Form I-821 04/11/18Page 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 03/31/2019 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 whogranted you TPS. USCIS Immigration Judge/Board of Immigration AppealsAre 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 04/11/18Page 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 UsedProvide 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 Address4.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 physicaladdress (where you live)? Yes NoIf you answered "No" to Item Number 5., please provide your physical address below. U.S. Physical Address6.a.Street Number and Name 6.b. Apt. Ste. Flr. 6.c.City or Town 6.d.State 6.e.ZIP Code Other Information7.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 Birth11.b.Other Date of Birth (mm/dd/yyyy)(mm/dd/yyyy)12.Gender Male Female13.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 04/11/18Page 3 of 13 Part 2. Information About You (continued)18. Date of Current Marriage (if currently married)(mm/dd/yyyy) U.S. Entry Information19.Date of Last Entry into the United States(mm/dd/yyyy) 20.Immigration Status (or Lack of Status) When You LastEntered the United States (for example, visitor, student,no status) Place of Last Entry into the United States21.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 StatesExpired or Will Expire (as shown on Form I-94 orCrewman's Landing Permit (Form I-95)) (mm/dd/yyyy orduration of status (D/S) 25.Passport Number (most recent passport) (if any) (If youhave other expired or valid passports, please list all ofthem and provide all information requested below abouteach passport.) 27.Additional Passport or Travel Document Number 28.Additional Passport or Travel Document Number 29.Country of Issuance for most recent Passport or TravelDocument 30.Expiration Date for most recent Passport or TravelDocument (mm/dd/yyyy) 26.Travel Document Number (if any) Your Current Immigration Status31.Current Immigration Status or Lack of Status 32.Are you now or were you EVER in immigrationproceedings? Yes NoIf 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 Proceedingswere Held (or are currently being held) (if applicable) 35.Locations Where Your Federal Court ProceedingsRegarding Immigration Issues were Held (or are currentlybeing held) (if applicable) Dates for Your Proceedings From (mm/dd/yyyy) To (mm/dd/yyyy) NOTE:240 If your proceedings are ongoing, leave the 223To224 date blank.240 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 Information1.Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino2.Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Present36.c. Form I-821 04/11/18Page 4 of 13 Part 3. Biographic Information (continued)5.Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other6.Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/OtherHeightFeetInches 3. 4.WeightPounds 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) A-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.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 NoIf yes, what dates did he or she have TPS? From (mm/dd/yyyy)To (mm/dd/yyyy) 10.a.10.b. Present10.c. I do not know the dates10.d.11.Is your spouse's TPS still valid? (if known) Yes No I Do Not Know 8.b. State Form I-821 04/11/18Page 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 requ