Immigration I-821d Form

IMMIGRATION I-821D — CONSIDERATION OF DEFERRED ACTION FOR CHILDHOOD ARRIVALS

This I-821D Application is executed by Applicant Name: and Representative Name: for the purpose of requesting consideration of deferred action and related ancillary benefits.

RECITALS

WHEREAS, Applicant affirms that Applicant was brought to the United States while under the age of majority and seeks consideration of deferred action based on the standards applicable to childhood arrivals;

WHEREAS, Representative has agreed to assist Applicant in preparing and transmitting this form and supporting documentation, and to represent Applicant in communications related to this application if authorized below;

WHEREAS, Applicant and Representative acknowledge that the granting of deferred action is discretionary and does not constitute formal immigration status, but may permit consideration for certain benefits consistent with governing authority;

NOW, THEREFORE, in consideration of the mutual covenants set forth herein and for other good and valuable consideration, the parties agree as follows.

1. DEFINITIONS

For purposes of this application, the following definitions apply: "Applicant" means the individual identified above; "Representative" means the person or organization identified above that assists the Applicant; "Application" means this completed I-821D form together with supporting documentation submitted in connection with the request for consideration of deferred action.

2. ELIGIBILITY DECLARATIONS

Applicant affirms under penalty of perjury that Applicant meets each of the following eligibility statements. Check all that apply and provide requested dates where applicable.

Month: Day: Year:

I arrived in the United States under the age of 16.

I have continuously resided in the United States since the date listed above and prior to the effective cut-off date relevant to this request.

I am currently in school, have graduated from high school, obtained a general education development (GED) certificate, or am an honorably discharged veteran of the U.S. Armed Forces.

3. PERSONAL INFORMATION

4. BIOGRAPHIC INFORMATION

Date of birth: Month: Day: Year:

Gender: Marital status:

5. CONTACT INFORMATION

6. IMMIGRATION AND CRIMINAL HISTORY

Have you ever been arrested, charged, or convicted of a crime in the United States or abroad?
No    Yes — If yes, explain below.

Have you ever been removed, ordered removed, or placed in deportation proceedings?
No    Yes — If yes, explain below.

7. EDUCATION / EMPLOYMENT STATUS

Current status (check all that apply):
In school    Graduated high school or obtained GED    Employed    Unemployed

8. CERTIFICATION, AUTHORIZATION AND REPRESENTATIONS

Applicant declares under penalty of perjury under the laws of the United States that the information contained in this application and attachments is true, correct, and complete to the best of Applicant's knowledge. Applicant understands that any willful misrepresentation or false statement may subject Applicant to penalties under law and may be grounds for denial of the request and subsequent civil or criminal action.

Applicant authorizes the collection and examination of biometric information and background checks as required to adjudicate this request. Applicant further authorizes the release of information to governmental entities and other parties as necessary for the adjudication, enforcement, or appeal of the request.

Applicant acknowledges that deferred action is a discretionary determination and does not by itself confer lawful permanent residence, change Applicant's immigration classification, or provide a path to citizenship. Applicant understands that deferred action may be terminated at any time and that any related benefits are subject to the discretion of the appropriate authorities.

9. NOTICES

Notices or any correspondence required or permitted under this application shall be delivered to Applicant at the mailing address provided above or to Representative at the address provided by Representative. Delivery by mail, courier, or hand delivery to the stated address shall be deemed effective upon receipt.

10. MISCELLANEOUS PROVISIONS

Governing Law: This Application and any dispute arising out of or related to it shall be governed by the substantive laws of the United States and applicable federal immigration statutes and regulations, without regard to choice of law principles.

Entire Agreement: This Application, including all attachments and declarations, constitutes the entire agreement between Applicant and Representative with respect to the subject matter hereof and supersedes all prior understandings and communications, whether written or oral.

Severability: If any provision of this Application is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the maximum extent permitted by law.

Amendments and Waiver: No amendment to this Application will be effective unless in writing and signed by Applicant and Representative. No failure or delay by any party in exercising any right shall operate as a waiver of that right.

Counterparts: This Application may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. REPRESENTATIVE AUTHORIZATION (OPTIONAL)

Applicant may authorize Representative to receive notices and act on Applicant's behalf in communications related to this Application. To authorize Representative, Applicant must sign below and provide the Representative's contact information.

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