USCIS Form I-821 "Application for Temporary Protected Status"

What Is USCIS Form I-821?

This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on April 11, 2018 and used country-wide. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on April 11, 2018;
  • The latest available edition released by the U.S. Department of Homeland Security - Citizenship and Immigration Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of USCIS Form I-821 by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.

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Download USCIS Form I-821 "Application for Temporary Protected Status"

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USCIS
Application for Temporary Protected Status
Form I-821
Department of Homeland Security
OMB No. 1615-0043
Expires 03/31/2019
U.S. Citizenship and Immigration Services
For USCIS Use Only
Receipt
Action Block
Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:
Remarks
Received:
Sent:
To be completed
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
by an Attorney
Form G-28 or
(if applicable)
USCIS Online Account Number (if any)
or Accredited
G-28I is
Representative (if any).
attached.
► START HERE - Type or print in black ink.
Part 1. Type of Application (select one)
Are you also filing a request for employment authorization?
NOTE: Select the box for Item Number 1.a., 1.b., or 2. If
3.a.
Yes, I am requesting an Employment Authorization
applicable, select the box for Item Number 3.a. or 3.b. For
Document (EAD), and I am filing Form I-765,
Item Number 4., enter the name of the designated TPS country.
Application for Employment Authorization, together
with my Form I-821.
1.a.
This is my initial (first time) application for
3.b.
No, I am not currently requesting an EAD.
Temporary Protected Status (TPS). I do not currently
have TPS.
Name of designated TPS country under which you are
4.
applying.
1.b.
This is my re-registration application for TPS. I
currently have TPS, and am applying to re-register.
NOTE: If you have previously applied or have a
pending application for TPS, but do not currently
Part 2. Information About You
have TPS, select Item Number 1.a. and describe
each time that you previously applied, including the
Your Full Name
receipt number (if available) and the outcome (if any)
1.a. Family Name
of each application. If you currently have a pending
(Last Name)
TPS application, please also describe when you filed
1.b. Given Name
it and the application receipt number (if available) in
(First Name)
Part 11. Additional Information. If you do not
recall or have incomplete information on your prior
1.c. Middle Name
TPS applications, please provide the information you
can, even if incomplete.
2.
If you selected Item Number 1.b., please indicate who
granted you TPS.
USCIS
Immigration Judge/Board of Immigration Appeals
Form I-821 04/11/18
Page 1 of 13
USCIS
Application for Temporary Protected Status
Form I-821
Department of Homeland Security
OMB No. 1615-0043
Expires 03/31/2019
U.S. Citizenship and Immigration Services
For USCIS Use Only
Receipt
Action Block
Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:
Remarks
Received:
Sent:
To be completed
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
by an Attorney
Form G-28 or
(if applicable)
USCIS Online Account Number (if any)
or Accredited
G-28I is
Representative (if any).
attached.
► START HERE - Type or print in black ink.
Part 1. Type of Application (select one)
Are you also filing a request for employment authorization?
NOTE: Select the box for Item Number 1.a., 1.b., or 2. If
3.a.
Yes, I am requesting an Employment Authorization
applicable, select the box for Item Number 3.a. or 3.b. For
Document (EAD), and I am filing Form I-765,
Item Number 4., enter the name of the designated TPS country.
Application for Employment Authorization, together
with my Form I-821.
1.a.
This is my initial (first time) application for
3.b.
No, I am not currently requesting an EAD.
Temporary Protected Status (TPS). I do not currently
have TPS.
Name of designated TPS country under which you are
4.
applying.
1.b.
This is my re-registration application for TPS. I
currently have TPS, and am applying to re-register.
NOTE: If you have previously applied or have a
pending application for TPS, but do not currently
Part 2. Information About You
have TPS, select Item Number 1.a. and describe
each time that you previously applied, including the
Your Full Name
receipt number (if available) and the outcome (if any)
1.a. Family Name
of each application. If you currently have a pending
(Last Name)
TPS application, please also describe when you filed
1.b. Given Name
it and the application receipt number (if available) in
(First Name)
Part 11. Additional Information. If you do not
recall or have incomplete information on your prior
1.c. Middle Name
TPS applications, please provide the information you
can, even if incomplete.
2.
If you selected Item Number 1.b., please indicate who
granted you TPS.
USCIS
Immigration Judge/Board of Immigration Appeals
Form I-821 04/11/18
Page 1 of 13
Part 2. Information About You (continued)
Other Information
7.
Alien Registration Number (A-Number) (if any)
Other Names Used
A-
Provide all other names you have used since birth, including
8.
USCIS Online Account Number (if any)
aliases, maiden name, and nicknames. If you need extra space
to complete this section, use the space provided in Part 11.
Additional Information.
9.
U.S. Social Security Number (if any)
2.a. Family Name
(Last Name)
2.b. Given Name
10.
Date of Birth (mm/dd/yyyy)
(First Name)
2.c. Middle Name
Other Dates of Birth Used (if any)
3.a. Family Name
Provide all other dates of birth you have ever used. If you need
(Last Name)
extra space to complete this section, use the space provided in
3.b. Given Name
Part 11. Additional Information.
(First Name)
11.a. Other Date of Birth
3.c. Middle Name
(mm/dd/yyyy)
11.b. Other Date of Birth
U.S. Mailing Address
(USPS ZIP Code Lookup)
(mm/dd/yyyy)
4.a. In Care Of Name
12.
Gender
Male
Female
13.
City/Town/Village of Birth
4.b. Street Number
and Name
14.
Country of Birth
4.c.
Apt.
Ste.
Flr.
4.d. City or Town
Countries of Residence (Before entering the U.S.)
4.e. State
4.f.
ZIP Code
15.a.
15.b.
5.
Is your current mailing address the same as your physical
address (where you live)?
Yes
No
15.c.
15.d.
If you answered "No" to Item Number 5., please provide your
physical address below.
Country or Countries of Citizenship or Nationality (if any)
(List all countries that apply.)
U.S. Physical Address
16.a.
6.a. Street Number
and Name
16.b.
6.b.
Apt.
Ste.
Flr.
16.c.
16.d.
6.c. City or Town
Your Marital Information
6.d. State
6.e. ZIP Code
17.
Current Marital Status (Select only one box)
Married
Single, Never Married
Divorced
Widowed
Separated
Marriage Annulled
Other
Form I-821 04/11/18
Page 2 of 13
Part 2. Information About You (continued)
Your Current Immigration Status
31.
Current Immigration Status or Lack of Status
18.
Date of Current Marriage (if currently married)
(mm/dd/yyyy)
32.
Are you now or were you EVER in immigration
U.S. Entry Information
proceedings?
Yes
No
19.
Date of Last Entry into the United States
If you answered "Yes" to Item Number 32., provide the
(mm/dd/yyyy)
following information.
20.
Immigration Status (or Lack of Status) When You Last
Type of Proceedings (Select all boxes that apply):
Entered the United States (for example, visitor, student,
33.a.
Immigration Court (before an Immigration Judge)
no status)
33.b.
Board of Immigration Appeals (BIA)
33.c.
I am no longer in Department of Justice (DOJ) or
Place of Last Entry into the United States
Department of Homeland Security (DHS)
immigration proceedings, but I am or was in Federal
21.
U.S. Port of Entry (if any)
court proceedings regarding immigration issues.
34.
Locations Where Your DOJ and/or DHS Proceedings
22.a. City or Town
were Held (or are currently being held) (if applicable)
35.
Locations Where Your Federal Court Proceedings
22.b. State
Regarding Immigration Issues were Held (or are currently
being held) (if applicable)
23.
Form I-94 Arrival-Departure Record Number (if any)
24.
Date Your Authorized Period of Stay in the United States
Dates for Your Proceedings
Expired or Will Expire (as shown on Form I-94 or
Crewman's Landing Permit (Form I-95)) (mm/dd/yyyy or
NOTE: If your proceedings are ongoing, leave the “To” date
duration of status (D/S)
blank. If you have been in more than one type of proceedings,
or in Federal Court, list dates for each time period.
25.
Passport Number (most recent passport) (if any) (If you
36.a.
From (mm/dd/yyyy)
have other expired or valid passports, please list all of
them and provide all information requested below about
36.b.
To (mm/dd/yyyy)
each passport.)
36.c.
Present
26.
Travel Document Number (if any)
Part 3. Biographic Information
27.
Additional Passport or Travel Document Number
1.
Ethnicity (Select only one box)
Hispanic or Latino
28.
Additional Passport or Travel Document Number
Not Hispanic or Latino
2.
Race (Select all applicable boxes)
29.
Country of Issuance for most recent Passport or Travel
White
Document
Asian
Black or African American
30.
Expiration Date for most recent Passport or Travel
American Indian or Alaska Native
Document (mm/dd/yyyy)
Native Hawaiian or Other Pacific Islander
Form I-821 04/11/18
Page 3 of 13
Part 3. Biographic Information (continued)
Mailing Address of Spouse
4.a. Street Number
3.
Height
Feet
Inches
and Name
4.
Weight
Pounds
4.b.
Apt.
Ste.
Flr.
5.
Eye Color (Select only one box)
4.c. City or Town
Black
Blue
Brown
4.d. State
4.e. ZIP Code
Gray
Green
Hazel
4.f.
Province
Maroon
Pink
Unknown/Other
4.g. Postal Code
4.h. Country
6.
Hair Color (Select only one box)
Bald (No hair)
Black
Blond
Brown
Gray
Red
Other Information About Your Current Spouse
Sandy
White
5.
Your Spouse's Date of Birth
Unknown/Other
(mm/dd/yyyy)
6.
Date of Marriage to Your Current Spouse
Part 4. Information About Your Current Spouse
(mm/dd/yyyy)
(if any)
7.
Place of Marriage to Your Current Spouse
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
8.a. City or Town
space to complete this section on all former spouses and all of
your children, please use the space provided in Part 11.
8.b. State
Additional Information.
Provide the following information about your current spouse (if
8.c. Province (if any)
married).
8.d. Country
1.
USCIS Online Account Number (if any and if known)
9.
If you know, has your current spouse EVER had TPS?
2.
A-Number (if any and if known)
Yes
No
A-
If yes, what dates did he or she have TPS?
3.a. Family Name
(Last Name)
10.a.
From (mm/dd/yyyy)
3.b. Given Name
(First Name)
10.b.
To (mm/dd/yyyy)
3.c. Middle Name
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
Form I-821 04/11/18
Page 4 of 13
Second Marriage
Part 5. Information About Your Former
Spouses (if any)
11.a. Family Name
(Last Name)
Complete this section only if you are filing a late initial
11.b. Given Name
application for TPS. See the form instructions for information
(First Name)
on requirements for late initial filing for TPS. If you need extra
11.c. Middle Name
space to complete this section on all former spouses or all of
your children, please use the space provided in Part 11.
12.
Nationalities of Former Spouse
Additional Information.
Names of All Your Former Spouses (if any)
13.
A-Number of Former Spouse (if any and if known)
First Marriage
A-
1.a. Family Name
14.
Date of Birth of Former Spouse
(Last Name)
(mm/dd/yyyy)
1.b. Given Name
(First Name)
15.
Date of Death if Former Spouse Deceased
1.c. Middle Name
(mm/dd/yyyy)
2.
Nationalities of Former Spouse
Dates of Marriage to Former Spouse
16.a.
From (mm/dd/yyyy)
3.
A-Number of Former Spouse (if any and if known)
16.b.
To (mm/dd/yyyy)
A-
17.
How Marriage Ended (for example, divorce, widowed,
annulled)
4.
Date of Birth of Former Spouse
(mm/dd/yyyy)
5.
Date of Death if Former Spouse Deceased
18.
Did or does this former spouse have TPS (if known)?
(mm/dd/yyyy)
Yes
No
I Do Not Know
Dates of Marriage to Former Spouse
If yes, what dates did he or she have TPS (if known)?
6.a.
From (mm/dd/yyyy)
19.a. From (mm/dd/yyyy)
6.b.
To (mm/dd/yyyy)
19.b.
To (mm/dd/yyyy)
How Marriage Ended (for example, divorce, widowed,
7.
19.c.
Present
annulled)
19.d.
I do not know the dates
20.
Is this former spouse currently applying for or re-
registering for TPS (if known)?
8.
Did or does this former spouse have TPS (if known)?
Yes
No
I Do Not Know
Yes
No
I Do Not Know
If yes, what dates did he or she have TPS (if known)?
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 re-
registering for TPS (if known)?
Yes
No
I Do Not Know
Form I-821 04/11/18
Page 5 of 13