Immigration I-821 Application

IMMIGRATION I-821 APPLICATION

Applicant Name:   A-Number:

RECITALS

WHEREAS, Applicant is an individual seeking temporary protected status based on designation or an eligible ground under applicable immigration regulations; and

WHEREAS, Applicant certifies that the information provided herein is true, complete, and submitted for the purpose of establishing eligibility for temporary protection consistent with the controlling immigration statutes and regulations; and

WHEREAS, Applicant understands that submission of this application imposes an obligation to disclose material facts, to provide supporting evidence, and to cooperate with immigration authorities in connection with adjudication;

NOW, THEREFORE, the Applicant submits this Application for Temporary Protected Status (I-821) and certifies, under penalty of perjury, the truth and completeness of all statements and supporting documentation provided.

1. APPLICANT INFORMATION

Date of Birth:   City of Birth:   Country of Birth:

Country of Citizenship:   Gender:

Height:   Weight:   Eye Color:   Hair Color:

2. BASIS FOR APPLICATION

Registration Type: Initial Registration Re-registration Other   If Other, explain:

3. PHYSICAL PRESENCE AND CONTINUOUS RESIDENCE

Date of Initial Entry to the United States:   Place of Entry (City, State):

Continuous Residence From:   To:

4. CRIMINAL HISTORY AND IMMIGRATION VIOLATIONS

Answer each question. Mark Yes or No and provide explanation where required.

Have you ever been arrested, charged, or convicted of any crime?   Yes No

Have you ever been removed, deported, or ordered excluded from the United States?   Yes No

5. EMPLOYMENT, EDUCATION, AND DEPENDENTS

Occupation:   Employer Phone:

6. SUPPORTING DOCUMENTATION

Applicant must submit all required evidence. Check all documents included with this submission:

Passport or travel document
Birth certificate or equivalent
Evidence of entry (I-94, admission stamp, etc.)
Certified court dispositions (if applicable)
Photographs as required

7. REPRESENTATIONS, UNDERSTANDINGS, AND CERTIFICATIONS

By signing below, Applicant certifies, under penalty of perjury under the laws governing immigration adjudications, that:

1. All statements made in this application and in supporting documents are true and complete to the best of Applicant’s knowledge.
2. Applicant understands that any material misrepresentation or willful failure to disclose information may result in denial of this application and may subject Applicant to civil and criminal penalties, including removal from the United States.
3. Applicant authorizes the immigration authorities to verify information supplied herein, to obtain records, and to conduct background checks as necessary for adjudication.

8. NOTICES, AMENDMENTS, AND WAIVER

Notices to Applicant will be sent to the mailing address provided. Applicant must notify immigration authorities in writing of any change of address or other material change in circumstances within the time required by regulation. Any amendment to this application must be made in writing and acknowledged by the adjudicating authority. Failure to comply with notice requirements may result in dismissal of the application.

9. GOVERNING LAW, ENTIRE AGREEMENT, SEVERABILITY

This application shall be governed by the immigration laws and regulations of the United States and the applicable administrative rules. This document, together with accompanying sworn statements and supporting evidence, constitutes the entire submission for the relief sought and supersedes any prior representations made for the same purpose. If any provision of this application is held invalid, the remainder shall continue in full force and effect.

10. PRIVACY AND RELEASE

Applicant acknowledges that personal information contained in this application will be maintained in government records and may be used and disclosed in accordance with applicable law. Applicant authorizes release of records and information to the extent necessary for adjudication and enforcement of immigration law.

11. DECLARATION, CERTIFICATION, AND SIGNATURE

I declare under penalty of perjury that I have provided true and complete answers to the questions on this application and all required supporting documentation. I understand that knowingly providing false information may subject me to penalties under the law including denial of this application and removal proceedings.

12. REPRESENTATIVE (IF ANY)

Does Applicant have an authorized representative?   Yes No

DECLARATION OF PREPARER

If someone prepared this application on behalf of Applicant, that preparer must complete the declaration below and certify the information is true and complete to the best of the preparer’s knowledge.

I certify, under penalty of perjury, that I prepared this application at the request of the applicant and based solely on information provided by the applicant.

Sign Now