Form I-821D 04/24/19 To Be Completed by an Attorney or Accredited Representative, if any. For USCIS Use Only Sent: / / / Consideration of Deferred Action for Childhood Arrivals Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form I-821D OMB No. 1615-0124 Expires 04/30/2021 Attorney State Bar Number (if any): Action BlockReceiptRemarks Resubmitted: / / / Returned: / / /Case ID:RelocatedRequestor interviewed on Select this box if Form G-28 is attached to represent the requestor. Received: / / /START HERE - Type or print in black ink. Read Form I-821D Instructions for information on how to complete this form. A- Part 1. Information About You (For Initial and Renewal Requests)3.a.Family Name (Last Name) 3.b.Given Name (First Name) 3.c.Middle Name Full Legal NameFor this Renewal request, my most recent period of Deferred Action for Childhood Arrivals expires onI am requesting:(mm/dd/yyyy) Initial Request - Consideration of Deferred Action for Childhood Arrivals Renewal Request - Consideration of Deferred Action for Childhood Arrivals 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 1. 2. U.S. Mailing Address (Enter the same address on Form I-765)4.a.In Care Of Name (if applicable) Street Number and Name4.b. 4.c. Flr. Ste. Apt.ORAND Removal Proceedings InformationAre 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)?5. Yes NoNOTE: The term 223removal proceedings224 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. Currently in Proceedings (Active) Currently in Proceedings (Administratively Closed) Terminated Subject to a Final Order5.f.Most Recent Date of Proceedings5.a.5.b.5.c.5.d.Status or outcome:If you answered "Yes" to Item Number 5., you must select a box below indicating your current status or outcome of your removal proceedings.5.g.Location of Proceedings (mm/dd/yyyy) Other. Explain in Part 8. Additional Information.5.e. ZIP Code4.f. State4.e. City or Town4.d. Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form I-821D 04/24/19 Other InformationCurrent Country of Residence11.Country of Citizenship or NationalityMarital Status12. Single Married Divorced Widowed13.Family Name (Last Name) Given Name (First Name) Middle Name Other Names Used (If Applicable)14.a.14.b.14.c.If you need additional space, use Part 8. Additional Information.8.Gender Male FemaleDate of Birth (mm/dd/yyyy)10.a. City/Town/Village of Birth 9. Country of Birth 10.b. A- Alien Registration Number (A-Number) (if any)6. 7.U.S. Social Security Number (if any) Part 1. Information About You (For Initial and Renewal Requests) (continued)Hair Color (Select only one box) 20. Black Brown Red White Unknown/ Other Sandy Gray Blond Bald (No hair)Height18.WeightPoundsFeetInches 17. Black Brown Green Maroon Pink Hazel Gray Blue 19.Eye Color (Select only one box) Unknown/Other Part 2. Residence and Travel Information (For Initial and Renewal Requests) 1.I have been continuously residing in the U.S. since at least June 15, 2007, up to the present time. Yes NoFor Renewal Requests: List only the addresses where you resided since you submitted your last Form I-821D that was approved.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.If you require additional space, use Part 8. Additional Information.16.Race (Select all applicable boxes)Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White Asian Black or African American Processing Information15.Not Hispanic or Latino Hispanic or Latino Ethnicity (Select only one box)NOTE:240 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. Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form I-821D 04/24/19 3.c.City or Town 3.d.State3.e.ZIP CodeStreet Number and Name3.a. 3.b. Address 1Dates at this residence (mm/dd/yyyy)From To 3.f. Flr. Ste. Apt.2.c.City or Town 2.d.State2.e.ZIP CodeStreet Number and Name2.a. 2.b. Present AddressDates at this residence (mm/dd/yyyy)From To Present2.f. Flr. Ste. Apt. Part 2. Residence and Travel Information (For Initial and Renewal Requests) (continued)4.c.City or Town 4.d.State4.e.ZIP CodeStreet Number and Name4.a. 4.b. Address 2Dates at this residence (mm/dd/yyyy)From To 4.f. Flr. Ste. Apt. 7.a. 7.b.Reason for Departure (mm/dd/yyyy)Departure Date (mm/dd/yyyy)Return Date 7.c.Departure 28.Have you left the United States without advance parole on or after August 15, 2012? Yes NoWhat country issued your last passport? 9.a.Passport Number 9.b.9.c.(mm/dd/yyyy)Passport Expiration Date Border Crossing Card Number (if any) 10.Departure 16.a. 6.b.Reason for Departure (mm/dd/yyyy)Departure Date (mm/dd/yyyy)Return Date 6.c. Travel InformationFor Initial Requests: List all of your absences from the United States since June 15, 2007.If you require additional space, use Part 8. Additional Information.For Renewal Requests: List only your absences from the United States since you submitted your last Form I-821D that was approved. City or Town 5.d.State5.e.ZIP Code 5.f.5.c.Street Number and Name5.a. 5.b.Address 3Dates at this residence (mm/dd/yyyy)From To Flr. Ste. Apt.I initially arrived and established residence in the U.S. prior to 16 years of age. Part 3. For Initial Requests Only1. Yes No(mm/dd/yyyy)Date of Initial Entry into the United States (on or about) 2.Place of Initial Entry into the United States 3. Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Form I-821D 04/24/19 Immigration Status on June 15, 2012 (e.g., No Lawful Status, Status Expired, Parole Expired)4.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) 5.c.Were you EVER issued an Arrival-Departure Record (Form I-94, I-94W, or I-95)?5.a. Yes NoIf you answered "Yes" to Item Number 5.a., provide your Form I-94, I-94W, or I-95 number (if available).5.b. 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 (mm/dd/yyyy)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. 8. Education Information Service Start Date (mm/dd/yyyy) (mm/dd/yyyy)Discharge Date Type of Discharge 9.b.9.c.9.d. Military Service Information 9.Were you a member of the U.S. Armed Forces or U.S. Coast Guard? Yes NoMilitary Branch 9.a.If you answered "Yes" to Item Number 9., you must provide responses to Item Numbers 9.a. - 9.d.Have you EVER engaged in, do you continue to engage in, or plan to engage in terrorist activities? No Yes3.Are you NOW or have you EVER been a member of a gang? No Yes4.If you answered "Yes," you must include a certified court disposition, arrest record, charging document, sentencing record, etc., for each arrest.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- or