Form I-821, Application for TPS Instructions
This form contains 478 fields organized into 54 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Part 11. Additional Information. If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1. A. Family Name (Last Name). (This field is pre-populated from Part 1.) | Text |
This field is pre-populated with the family name (last name) of the applicant from Part 1.
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| Part 11. Additional Information. 1. B. Given Name (First Name) (This field is pre-populated from Part 1.) | Text |
This field is pre-populated with the given name (first name) of the applicant from Part 1.
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| Part 11. Additional Information. 1. C. Middle Name (This field is pre-populated from Part 1.) | Text |
This field is pre-populated with the middle name of the applicant from Part 1.
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| Part 11. Additional Information. 3. A. Enter Page Number | Text |
Enter the page number where additional information is being provided.
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| Part 11. Additional Information. 3. B. Enter Part Number | Text |
Enter the part number where additional information is being provided.
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| Part 11. Additional Information. 3. C. Enter Item Number | Text |
Enter the item number where additional information is being provided.
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| Part 11. Additional Information. 3. D. Enter additional information | Text |
Enter any additional information that is relevant to the application.
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| Part 11. Additional Information. 4. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 11. Additional Information. 4. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 11. Additional Information. 4. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 11. Additional Information. 4. D. Enter additional information | Text |
Provide any additional information that is relevant to your application.
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| Part 11. Additional Information. 5. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 11. Additional Information. 5. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 11. Additional Information. 5. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 11. Additional Information. 6. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 11. Additional Information. 6. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 11. Additional Information. 6. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 11. Additional Information. 7. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced.
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| Part 11. Additional Information. 7. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced.
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| Part 11. Additional Information. 7. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced.
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| Part 11. Additional Information. 7. D. Enter additional information | Text |
Provide any additional information relevant to your application that has not been covered in other sections of the form.
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| Part 11. Additional Information. 5. D. Enter additional information | Text |
Provide any additional information relevant to your application that has not been covered in other sections of the form.
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| Part 11. Additional Information. 6. D. Enter additional information | Text |
Provide any additional information relevant to your application that has not been covered in other sections of the form.
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| Applicant's Information | ||
| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Signature. 6. B. Enter Date of Signature. Enter as 2 digit month, 2 digit day and 4 digit year. NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U S C I S may deny your application | Text |
Enter the date you signed the application. Use the format MM/DD/YYYY.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Contact Information. 3. Applicant's Daytime Telephone Number. Enter the telephone number including the area code or country code | Text |
Enter your daytime telephone number, including the area code or country code.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Contact Information. 4. Applicant's Mobile Telephone Number ( if any). Enter the telephone number including the area code or country code | Text |
Enter your mobile telephone number, if available, including the area code or country code.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Contact Information. 5. Enter Applicant's Email Address (if any) | Text |
Enter your email address, if available.
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| Applicant's Signature | ||
| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Signature. 6. A. Applicant's Signature. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Print and sign in ink | Text |
Provide the applicant's signature. This field cannot be signed digitally or have the name typewritten. Print and sign in ink.
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| Applicant's Statement | ||
| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. NOTE: Read the Penalties section of the Form I-8 21 Instructions before completing this part. You must file Form I-8 21 while in the United States. Applicant's Statement. NOTE: Select the box for either Item Number 1. A. or 1. B. If applicable, select the box for Item Number 2. 1. A. Select I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question | CheckBox |
Select this box if you can read and understand English, and you have read and understand every question and instruction on this application and your answer to every question.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Statement. 2. Select At my request, the preparer named in Part 10., prepared this application for me based only upon information I provided or authorized | CheckBox |
Select this checkbox if the preparer named in Part 10 prepared this application for you based only on the information you provided or authorized.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Statement. 2. Enter the preparer name in Part 10 | Text |
Enter the name of the preparer who helped you fill out this application, as mentioned in Part 10.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Statement. 1. B. Select The interpreter named in Part 9. read to me every question and instruction on this application and my answer to every question in a language in which I am fluent, and I understood everything | CheckBox |
Select this checkbox if the interpreter named in Part 9 read every question and instruction on this application to you in a language you are fluent in, and you understood everything.
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| Part 8. Applicant's Statement, Contact Information, Certification, and Signature. Applicant's Statement. 1. B. The interpreter named in Part 9. read to me every question and instruction on this application and my answer to every question in. Enter Language | Text |
Enter the language in which the interpreter named in Part 9 read every question and instruction to you.
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| Application Information | ||
| Part 1. Type of Application (Select one). 4. Enter Name of designated T P S country under which you are applying | Text |
Enter the name of the designated TPS country under which you are applying for Temporary Protected Status.
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| Application Type | ||
| 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 T P S country. 1. A. Select This is my initial (first time) application for Temporary Protected Status (T P S). I do not currently have T P S | CheckBox |
Select this box if this is your initial (first time) application for Temporary Protected Status (TPS) and you do not currently have TPS.
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| Part 1. Type of Application (Select one). 1. B. Select This is my re-registration application for T P S. I currently have TPS, and am applying to re-register. NOTE: If you have previously applied or have a pending application for T P S, but do not currently have T P S, 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 T P S 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 T P S applications, please provide the information you can, even if incomplete | CheckBox |
Select this box if this is your re-registration application for TPS and you currently have TPS. If you have previously applied or have a pending application for TPS, provide details in Part 11.
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| Part 1. Type of Application (Select one). 2. If you selected Item Number 1. B., please indicate who granted you T P S. Select U S C I S | CheckBox |
Select this box if USCIS granted you TPS.
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| Part 1. Type of Application (Select one). 2. If you selected Item Number 1. B., please indicate who granted you T P S. Select Immigration Judge/Board of Immigration Appeals | CheckBox |
Select this box if an Immigration Judge or the Board of Immigration Appeals granted you TPS.
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| Attorney/Representative Information | ||
| To be completed by an Attorney or Accredited Representative (if any). Select this box if Form G-28 or G-28 I is attached | CheckBox |
Check this box if you are an attorney or accredited representative and have attached Form G-28 or G-28I.
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| To be completed by an Attorney or Accredited Representative (if any). Enter Attorney State Bar Number (if applicable) | Text |
Enter the state bar number of the attorney if applicable.
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| To be completed by an Attorney or Accredited Representative (if any). Enter Attorney or Accredited Representative U S C I S Online Account Number (if any) | Text |
Enter the USCIS Online Account Number of the attorney or accredited representative, if available. The number should be up to 12 characters long.
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| Biographic Information | ||
| Part 3. Biographic Information. 1. Ethnicity (Select only one box). Select Hispanic or Latino | CheckBox |
Select this checkbox if you identify as Hispanic or Latino.
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| Part 3. Biographic Information. 1. Ethnicity (Select only one box). Select Not Hispanic or Latino | CheckBox |
Select this checkbox if you do not identify as Hispanic or Latino.
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| Part 3. Biographic Information. 2. Race (Select all applicable boxes). Select White | CheckBox |
Select this checkbox if you identify as White.
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| Part 3. Biographic Information. 2. Race (Select all applicable boxes). Select Asian | CheckBox |
Select this checkbox if you identify as Asian.
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| Part 3. Biographic Information. 2. Race (Select all applicable boxes). Select Black or African American | CheckBox |
Select this checkbox if your race is Black or African American.
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| Part 3. Biographic Information. 2. Race (Select all applicable boxes). Select American Indian or Alaska Native | CheckBox |
Select this checkbox if your race is American Indian or Alaska Native.
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| Part 3. Biographic Information. 2. Race (Select all applicable boxes). Select Native Hawaiian or Other Pacific Islander | CheckBox |
Select this checkbox if your race is Native Hawaiian or Other Pacific Islander.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Black | CheckBox |
Select this checkbox if your eye color is Black.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Blue | CheckBox |
Select this checkbox if your eye color is Blue.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Brown | CheckBox |
Select this checkbox if your eye color is Brown.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Gray | CheckBox |
Select this checkbox if your eye color is Gray.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Green | CheckBox |
Select this checkbox if your eye color is Green.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Hazel | CheckBox |
Select 'Hazel' if your eye color is hazel.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Maroon | CheckBox |
Select 'Maroon' if your eye color is maroon.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Pink | CheckBox |
Select 'Pink' if your eye color is pink.
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| Part 2. Biographic Information. 5. Eye Color (Select only one box). Select Unknown/Other | CheckBox |
Select 'Unknown/Other' if your eye color does not fit any of the listed categories.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Bald (No hair) | CheckBox |
Select 'Bald (No hair)' if you have no hair.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Black | CheckBox |
Select 'Black' if your hair color is black.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Blond | CheckBox |
Select 'Blond' if your hair color is blond.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Brown | CheckBox |
Select 'Brown' if your hair color is brown.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Gray | CheckBox |
Select 'Gray' if your hair color is gray.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Red | CheckBox |
Select 'Red' if your hair color is red.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Sandy | CheckBox |
Select 'Sandy' if your hair color is sandy.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select White | CheckBox |
Select 'White' if your hair color is white.
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| Part 2. Biographic Information. 6. Hair Color (Select only one box). Select Unknown/Other | CheckBox |
Select your hair color from the available options. If your hair color is not listed, select 'Unknown/Other'.
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| Part 2. Biographic Information. 3. Height. Feet (select from list) | ComboBox |
Select your height in feet from the provided list.
5
3
6
4
8
7
2
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| Part 2. Biographic Information. 3. Height. Inches (select from list) | ComboBox |
Select your height in inches from the provided list.
9
3
5
1
6
0
4
8
7
10
11
2
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| Part 2. Biographic Information. 4. Weight. Enter your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter "000". Do not enter your weight in kilograms. Pounds. Enter second digit | Text |
Enter the second digit of your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter '0'. Do not enter your weight in kilograms.
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| Part 2. Biographic Information. 4. Weight. Enter your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter "000". Do not enter your weight in kilograms. Pounds. Enter first digit | Text |
Enter the first digit of your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter '0'. Do not enter your weight in kilograms.
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| Part 2. Biographic Information. 4. Weight. Enter your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter "000". Do not enter your weight in kilograms. Pounds. Enter third digit | Text |
Enter the third digit of your weight in pounds. If you do not know your weight, or need to enter a weight under 30 pounds or over 699 pounds, enter '0'. Do not enter your weight in kilograms.
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| Child 1 Mailing Address | ||
| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. A. Enter Street Number and Name | Text |
Enter the street number and name for the mailing address of your first child.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. B. Select Apartment | CheckBox |
Select this checkbox if the mailing address of your first child includes an apartment.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. B. Select Suite | CheckBox |
Select this checkbox if the mailing address of your first child includes a suite.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. B. Select Floor | CheckBox |
Select this checkbox if the mailing address of your first child includes a floor number.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number for the mailing address of your first child.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. C. Enter City or Town | Text |
Enter the city or town for the mailing address of your first child.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. D. Select State from a List of States | ComboBox |
Select the state from the list for the mailing address of your first child.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. E. Enter ZIP Code | Text |
Enter the ZIP code for the mailing address of your first child.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. F. Enter the Province | Text |
Enter the province for the mailing address of your first child, if applicable.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. G. Enter the Postal Code | Text |
Enter the postal code for the mailing address of your first child.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. 5. H. Enter the Country | Text |
Enter the country for the mailing address of your first child.
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| Child 1 TPS Information | ||
| Part 6. Information About Your Children (if any). Child 1. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 6. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of your first child's Temporary Protected Status (TPS) in the format MM/DD/YYYY, if known.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 6. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of your first child's Temporary Protected Status (TPS) in the format MM/DD/YYYY, if known.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 7. If you know, is this child currently applying for or re-registering for TPS (if known)? Select Yes | CheckBox |
Select 'Yes' if your first child is currently applying for or re-registering for TPS.
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| Part 6. Information About Your Children (if any). Child 1. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 7. If you know, is this child currently applying for or re-registering for TPS (if known)? Select No | CheckBox |
Select 'No' if your first child is not currently applying for or re-registering for TPS.
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| Child 2 Personal Information | ||
| Part 6. Information About Your Children (if any). Child 2. 8. A. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of your second child.
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| Part 6. Information About Your Children (if any). Child 2. 8. B. Enter Given Name (First Name) | Text |
Enter the given name (first name) of your second child.
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| Part 6. Information About Your Children (if any). Child 2. 8. C. Enter Middle Name | Text |
Enter the middle name of your second child.
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| Part 6. Information About Your Children (if any). Child 2. 9. Enter U S C I S Online Account Number (if any and if known) | Text |
Enter the USCIS Online Account Number for your second child, if any and if known.
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| Child Information | ||
| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. F. Enter the Province | Text |
Enter the province of the mailing address for Child 2.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. G. Enter the Postal Code | Text |
Enter the postal code of the mailing address for Child 2. The maximum length is 9 characters.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. H. Enter the Country | Text |
Enter the country of the mailing address for Child 2.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 13. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of Child 2's Temporary Protected Status (TPS) in the format MM/DD/YYYY.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 13. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of Child 2's Temporary Protected Status (TPS) in the format MM/DD/YYYY.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 14. If you know, is this child currently applying for or re-registering for TPS (if known)? Select Yes | CheckBox |
Select 'Yes' if Child 2 is currently applying for or re-registering for TPS.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. If this child has or had TPS, please provide the dates of his or her TPS (if known). 14. If you know, is this child currently applying for or re-registering for TPS (if known)? Select No | CheckBox |
Select 'No' if Child 2 is not currently applying for or re-registering for TPS.
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| Part 6. Information About Your Children (if any). Child 1. 3. Enter Alien Registration Number (A. -Number) (if any and if known) | Text |
Enter the Alien Registration Number (A-Number) for Child 1, if any and if known. The maximum length is 9 characters.
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| Children Information | ||
| Part 6. Information About Your Children (if any). 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 or all of your children, please use the space provided in Part 11. Additional Information. Provide the following information about each of your children (if any). If you need extra space to complete this section, use the space provided in Part 11. Additional Information. Child 1. 1. A. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of your first child. Complete this section only if you are filing a late initial application for TPS.
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| Part 6. Information About Your Children (if any). Child 1. 1. B. Enter Given Name (First Name) | Text |
Enter the given name (first name) of your first child. Complete this section only if you are filing a late initial application for TPS.
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| Part 6. Information About Your Children (if any). Child 1. 1. C. Enter Middle Name | Text |
Enter the middle name of your first child. Complete this section only if you are filing a late initial application for TPS.
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| Part 6. Information About Your Children (if any). Child 1. 2. Enter U S C I S Online Account Number (if any and if known) | Text |
Enter the USCIS Online Account Number of your first child, if any and if known. This number can be up to 12 digits long.
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| Part 6. Information About Your Children (if any). Child 1. 4. Enter Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of birth of your first child in the format MM/DD/YYYY. Complete this section only if you are filing a late initial application for TPS.
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| Part 6. Information About Your Children (if any). Child 2. 10. Enter Alien Registration Number (A. -Number) (if any and if known) | Text |
Enter the Alien Registration Number (A-Number) for your second child, if any and if known. This number is typically assigned by the U.S. Citizenship and Immigration Services.
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| Children's Information | ||
| Part 6. Information About Your Children (if any). Child 2. 11. Enter Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of birth for your second child. Use the format MM/DD/YYYY.
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| Children's Mailing Address | ||
| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. A. Enter Street Number and Name | Text |
Enter the street number and name for the mailing address of your second child. Maximum length is 34 characters.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. B. Select Apartment | CheckBox |
Select this checkbox if the mailing address of your second child includes an apartment.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. B. Select Suite | CheckBox |
Select this checkbox if the mailing address of your second child includes a suite.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. B. Select Floor | CheckBox |
Select this checkbox if the mailing address of your second child includes a floor.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number for the mailing address of your second child. Maximum length is 6 characters.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. C. Enter City or Town | Text |
Enter the city or town for the mailing address of your second child. Maximum length is 20 characters.
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| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. D. Select State from a List of States | ComboBox |
Select the state from the provided list for the mailing address of your second child.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
|
| Part 6. Information About Your Children (if any). Child 2. Mailing Address. 12. E. Enter ZIP Code | Text |
Enter the ZIP code for the mailing address of your second child. Maximum length is 5 characters.
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| Citizenship Information | ||
| Part 2. Information About You. Other Dates of Birth Used (if any). 16. A. Enter Country or Countries of Citizenship or Nationality (if any) (List all countries that apply.) | Text |
Enter the country or countries of your citizenship or nationality. List all countries that apply.
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| Part 2. Information About You. Other Dates of Birth Used (if any). 16. B. Enter Country or Countries of Citizenship or Nationality (if any) (List all countries that apply.) | Text |
Enter the country or countries of your citizenship or nationality. List all countries that apply.
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| Part 2. Information About You. Other Dates of Birth Used (if any). 16. C. Enter Country or Countries of Citizenship or Nationality (if any) (List all countries that apply.) | Text |
Enter the country or countries of your citizenship or nationality. List all countries that apply.
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| Part 2. Information About You. Other Dates of Birth Used (if any). 16. D. Enter Country or Countries of Citizenship or Nationality (if any) (List all countries that apply.) | Text |
Enter the country or countries of your citizenship or nationality. List all countries that apply.
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| Criminal History | ||
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. A. Arrested, for breaking or violating any law or ordinance, excluding minor traffic violations? Select Yes | CheckBox |
Indicate whether you have ever been arrested for breaking or violating any law or ordinance, excluding minor traffic violations. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. A. Arrested, for breaking or violating any law or ordinance, excluding minor traffic violations? Select No | CheckBox |
Indicate whether you have ever been arrested for breaking or violating any law or ordinance, excluding minor traffic violations. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. B. Cited, charged, or indicted, for breaking or violating any law or ordinance, excluding minor traffic violations? Select Yes | CheckBox |
Indicate whether you have ever been cited, charged, or indicted for breaking or violating any law or ordinance, excluding minor traffic violations. Select 'Yes' if this applies to you.
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| Current Immigration Status | ||
| Part 2. Information About You. Your Current Immigration Status. 31. Enter Current Immigration Status or Lack of Status | Text |
Enter your current immigration status or indicate if you lack status.
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| Part 2. Information About You. Your Current Immigration Status. 32. Are you now or were you EVER in immigration proceedings? Select Yes | CheckBox |
Select 'Yes' if you are currently or have ever been in immigration proceedings.
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| Part 2. Information About You. Your Current Immigration Status. 32. Are you now or were you EVER in immigration proceedings? Select No | CheckBox |
Select 'No' if you are not currently and have never been in immigration proceedings.
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| Part 2. Information About You. Your Current Immigration Status. If you answered "Yes" to Item Number 32., provide the following information. Type of Proceedings (Select all boxes that apply). 33. A. Select Immigration Court (before an Immigration Judge) | CheckBox |
Select this box if you answered 'Yes' to being in immigration proceedings and the type of proceeding is before an Immigration Judge.
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| Part 2. Information About You. Your Current Immigration Status. If you answered "Yes" to Item Number 32., provide the following information. Type of Proceedings (Select all boxes that apply). 33. B. Select Board of Immigration Appeals (B I. A.) | CheckBox |
Select this box if you answered 'Yes' to being in immigration proceedings and the type of proceeding is before the Board of Immigration Appeals (B.I.A.).
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| Part 2. Information About You. Your Current Immigration Status. If you answered "Yes" to Item Number 32., provide the following information. Type of Proceedings (Select all boxes that apply). 33. C. Select I am no longer in Department of Justice (D O J) or Department of Homeland Security (D H S) immigration proceedings, but I am or was in Federal court proceedings regarding immigration issues | CheckBox |
Select this checkbox if you are no longer in Department of Justice (DOJ) or Department of Homeland Security (DHS) immigration proceedings, but you are or were in Federal court proceedings regarding immigration issues.
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| Part 2. Information About You. Your Current Immigration Status. 34. Enter Locations Where Your D O J and/or D H S Proceedings were Held (or are currently being held) (if applicable) | Text |
Enter the locations where your DOJ and/or DHS proceedings were held or are currently being held, if applicable.
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| Part 2. Information About You. Your Current Immigration Status. 35. Enter Locations Where Your Federal Court Proceedings Regarding Immigration Issues were Held (or are currently being held) (if applicable) | Text |
Enter the locations where your Federal court proceedings regarding immigration issues were held or are currently being held, if applicable.
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| Part 2. Information About You. Your Current Immigration Status. Dates for Your Proceedings. NOTE: If your proceedings are ongoing, leave the “To” date blank. If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period. 36. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of your proceedings in the format MM/DD/YYYY. If your proceedings are ongoing, leave the 'To' date blank. If you have been in more than one type of proceedings or in Federal Court, list dates for each time period.
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| Part 2. Information About You. Your Current Immigration Status. Dates for Your Proceedings. NOTE: If your proceedings are ongoing, leave the “To” date blank. If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period. 36. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of your proceedings in the format MM/DD/YYYY. If your proceedings are ongoing, leave this field blank. If you have been in more than one type of proceedings or in Federal Court, list dates for each time period.
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| Part 2. Information About You. Your Current Immigration Status. Dates for Your Proceedings. NOTE: If your proceedings are ongoing, leave the “To” date blank. If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period. 36. C. Select Present | CheckBox |
Select this checkbox if your current immigration proceedings are ongoing.
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| Current Spouse Information | ||
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 11. Is your spouse's T P S still valid? (if known). Select Yes | CheckBox |
Indicate whether your current spouse's Temporary Protected Status (TPS) is still valid. Select 'Yes' if it is valid.
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| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 11. Is your spouse's T P S still valid? (if known). Select No | CheckBox |
Indicate whether your current spouse's Temporary Protected Status (TPS) is still valid. Select 'No' if it is not valid.
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| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 11. Is your spouse's T P S still valid? (if known). Select I Do Not Know | CheckBox |
Indicate whether your current spouse's Temporary Protected Status (TPS) is still valid. Select 'I Do Not Know' if you are unsure.
|
| Part 4. Information About Your Current Spouse (if any). 2. Enter. A. Number (if any and if known) | Text |
Enter the Alien Number (A-Number) of your current spouse, if known. This number is typically 9 digits long.
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| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 8. B. Select State from a List of States | ComboBox |
Select the state where your current spouse resides from the provided list of states.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
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| Eligibility Criteria | ||
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 8. C. Any particularly serious crime committed in the United States? Select Yes | CheckBox |
Indicate whether you have ever been convicted of any particularly serious crime committed in the United States by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 8. C. Any particularly serious crime committed in the United States? Select No | CheckBox |
Indicate whether you have ever been convicted of any particularly serious crime committed in the United States by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. A. Have you EVER ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion? Select Yes | CheckBox |
Indicate whether you have ever ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. A. Have you EVER ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion? Select No | CheckBox |
Indicate whether you have ever ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. B. Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States? Select Yes | CheckBox |
Indicate whether you have ever committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. B. Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States? Select No | CheckBox |
Indicate whether you have ever committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. C. Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States? Select Yes | CheckBox |
Indicate whether you have ever or are now engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 9. C. Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States? Select No | CheckBox |
Indicate whether you have ever or are now engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States by selecting 'No'.
|
| Eligibility Information | ||
| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 1. A. I am a national of (or a person having no nationality who last habitually resided in the country of). Enter Country | Text |
Enter the country of which you are a national, or the country where you last habitually resided if you have no nationality.
|
| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 1. B. I entered the United States on the following date, and have resided in the United States since that time. Enter Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date you entered the United States and have resided since. Use the format MM/DD/YYYY.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 1. C. Have you EVER traveled to and entered another country, other than the one listed in Item Number 1. A. before you last entered the United States? Select Yes | CheckBox |
Select 'Yes' if you have ever traveled to and entered another country before your last entry into the United States.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 1. C. Have you EVER traveled to and entered another country, other than the one listed in Item Number 1. A. before you last entered the United States? Select No | CheckBox |
Select 'No' if you have never traveled to and entered another country before your last entry into the United States.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. If you answered "Yes" to Item Number 1. C., provide the information requested in Item Numbers 2. through 5. for EACH country you traveled to and entered prior to entering the United States. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 2. Enter Name of All the Other Countries to Which You Traveled and Entered Prior to Entering the United States | Text |
If you answered 'Yes' to traveling to another country before your last entry into the United States, list all the countries you traveled to and entered.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. Dates That You Were in the Other Country or Countries. 3. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of your stay in the other country or countries you traveled to before entering the United States. Use the format MM/DD/YYYY.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. Dates That You Were in the Other Country or Countries. 3. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of your stay in the other country or countries you traveled to before entering the United States. Use the format MM/DD/YYYY.
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| Eligibility Standards | ||
| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 4. Enter Your Immigration Status, if Any, in the Other Country (for example, citizen, legal permanent resident, refugee, asylee, visitor, student, temporary resident, or no status) | Text |
Enter your current immigration status in another country, such as citizen, legal permanent resident, refugee, asylee, visitor, student, temporary resident, or no status.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 5. Have you EVER been offered any immigration status by another country that you did not accept? Select Yes | CheckBox |
Select 'Yes' if you have ever been offered any immigration status by another country that you did not accept.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 5. Have you EVER been offered any immigration status by another country that you did not accept? Select No | CheckBox |
Select 'No' if you have never been offered any immigration status by another country that you did not accept.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 6. If you answered "Yes" to Item Number 5., please describe the country or countries, the nature of the immigration status you were offered, and the dates when it was offered | Text |
If you answered 'Yes' to the previous question, describe the country or countries, the nature of the immigration status you were offered, and the dates when it was offered.
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| Part 7. Eligibility Standards. Basis for Eligibility. Provide the following information. 7. If you answered “Yes” to Item Number 5., please describe why you chose not to accept the immigration status offered to you by the other country or countries | Text |
If you answered 'Yes' to the question about being offered immigration status by another country, describe why you chose not to accept the immigration status offered to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of.10. A. A crime (other than a purely political offense)? Select Yes | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a crime (other than a purely political offense). Select 'Yes' if applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 10. A. A crime (other than a purely political offense)? Select No | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a crime (other than a purely political offense). Select 'No' if not applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 10. B. A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? Select Yes | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act. Select 'Yes' if applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 10. B. A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? Select No | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act. Select 'No' if not applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 10. C. A conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? Select Yes | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act. Select 'Yes' if applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 10. C. A conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act? Select No | CheckBox |
Indicate whether you have ever been convicted of or committed acts that constitute the essential elements of a conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act. Select 'No' if not applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 11. Have you EVER been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when combined, total five years or more? Select Yes | CheckBox |
Indicate whether you have ever been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when combined, total five years or more. Select 'Yes' if applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 11. Have you EVER been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when combined, total five years or more? Select No | CheckBox |
Indicate whether you have ever been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when combined, total five years or more. Select 'No' if not applicable.
|
| Part 7. Eligibility Standards. Human Rights Violations. If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. A. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? Select Yes | CheckBox |
Indicate whether you have ever trafficked in or are currently trafficking in any controlled substance by selecting 'Yes'.
|
| Part 7. Eligibility Standards. Human Rights Violations. If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. A. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? Select No | CheckBox |
Indicate whether you have never trafficked in or are not currently trafficking in any controlled substance by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. B. Are you NOW or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? Select Yes | CheckBox |
Indicate whether you are now or have ever knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance by selecting 'Yes'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. B. Are you NOW or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? Select No | CheckBox |
Indicate whether you have never knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. C. Are you the spouse or child of an alien who unlawfully trafficked in any controlled substance? Select Yes | CheckBox |
Indicate whether you are the spouse or child of an alien who unlawfully trafficked in any controlled substance by selecting 'Yes'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. C. Are you the spouse or child of an alien who unlawfully trafficked in any controlled substance? Select No | CheckBox |
Indicate whether you are not the spouse or child of an alien who unlawfully trafficked in any controlled substance by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. D. Are you the spouse or child of an alien who assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? Select Yes | CheckBox |
Indicate whether you are the spouse or child of an alien who assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance by selecting 'Yes'.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. D. Are you the spouse or child of an alien who assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? Select No | CheckBox |
Indicate whether you are the spouse or child of an alien who has assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance. Select 'No' if this does not apply to you.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. E. Within the previous five years, have you EVER obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit activity? Select Yes | CheckBox |
Indicate whether, within the previous five years, you have obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit activity. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of or have you EVER committed acts which constitute the essential elements of. 12. E. Within the previous five years, have you EVER obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit activity? Select No | CheckBox |
Indicate whether, within the previous five years, you have obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit activity. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. A. Any activity to violate any law of the United States relating to espionage or sabotage? Select Yes | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any activity to violate any law of the United States relating to espionage or sabotage. Select 'Yes' if this applies to you.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. A. Any activity to violate any law of the United States relating to espionage or sabotage? Select No | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any activity to violate any law of the United States relating to espionage or sabotage. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. B. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? Select Yes | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. B. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? Select No | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information. Select 'No' if this does not apply to you.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. C. Any other unlawful activity in the United States? Select Yes | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any unlawful activity in the United States.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. C. Any other unlawful activity in the United States? Select No | CheckBox |
Indicate whether you have never engaged, or do not plan to engage, in any unlawful activity in the United States.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. D. Any activity in which a purpose is to oppose, control, or overthrow the Government of the United States by force, violence, or other unlawful means, including but not limited to participating in such activities, giving support to others involved in such activities, or being a member or representative of a terrorist organization? Select Yes | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in any activity aimed at opposing, controlling, or overthrowing the Government of the United States by force, violence, or other unlawful means.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 13. D. Any activity in which a purpose is to oppose, control, or overthrow the Government of the United States by force, violence, or other unlawful means, including but not limited to participating in such activities, giving support to others involved in such activities, or being a member or representative of a terrorist organization? Select No | CheckBox |
Indicate whether you have never engaged, or do not plan to engage, in any activity aimed at opposing, controlling, or overthrowing the Government of the United States by force, violence, or other unlawful means.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. A. Have you EVER or are you NOW engaged in terrorist activities? Select Yes | CheckBox |
Indicate whether you have ever engaged, or are currently engaged, in terrorist activities.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. A. Have you EVER or are you NOW engaged in terrorist activities? Select No | CheckBox |
Indicate whether you have never engaged, or are not currently engaged, in terrorist activities.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. B. Have you EVER or are you NOW engaged in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States? Select Yes | CheckBox |
Indicate whether you have ever engaged, or plan to engage, in activities in the United States that could have potentially serious adverse foreign policy consequences for the United States.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. B. Have you EVER or are you NOW engaged in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States? Select No | CheckBox |
Indicate whether you have ever engaged in or plan to engage in activities in the United States that could have serious adverse foreign policy consequences for the United States. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. C. Have you EVER been or are you NOW a member of the Communist or other totalitarian party, except when membership was involuntary? Select Yes | CheckBox |
Indicate whether you have ever been or are currently a member of the Communist or any other totalitarian party, except when membership was involuntary. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. C. Have you EVER been or are you NOW a member of the Communist or other totalitarian party, except when membership was involuntary? Select No | CheckBox |
Indicate whether you have ever been or are currently a member of the Communist or any other totalitarian party, except when membership was involuntary. Select 'No' if this does not apply to you.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. D. Have you EVER participated in Nazi persecution or genocide? Select Yes | CheckBox |
Indicate whether you have ever participated in Nazi persecution or genocide. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following. 14. D. Have you EVER participated in Nazi persecution or genocide? Select No | CheckBox |
Indicate whether you have ever participated in Nazi persecution or genocide. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. B. Cited, charged, or indicted, for breaking or violating any law or ordinance, excluding minor traffic violations? Select No | CheckBox |
Indicate whether you have ever been cited, charged, or indicted for breaking or violating any law or ordinance, excluding minor traffic violations, in the United States or any other country. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. C. Been convicted, fined, imprisoned, placed on probation, received a suspended sentence or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations? Select Yes | CheckBox |
Indicate whether you have ever been convicted, fined, imprisoned, placed on probation, received a suspended sentence, or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations, in the United States or any other country. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 15. C. Been convicted, fined, imprisoned, placed on probation, received a suspended sentence or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations? Select No | CheckBox |
Indicate whether you have ever been convicted, fined, imprisoned, placed on probation, received a suspended sentence, or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations, in the United States or any other country. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 19. Have you EVER been or do you intend to be involved in any other commercial vice? Select Yes | CheckBox |
Indicate whether you have ever been or intend to be involved in any other commercial vice. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 19. Have you EVER been or do you intend to be involved in any other commercial vice? Select No | CheckBox |
Indicate whether you have ever been or intend to be involved in any other commercial vice. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. A. Have you EVER been ordered removed, and been deported from the United States? Select Yes | CheckBox |
Indicate whether you have ever been ordered removed and deported from the United States. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. A. Have you EVER been ordered removed, and been deported from the United States? Select No | CheckBox |
Indicate whether you have ever been ordered removed and deported from the United States. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. B. Have you EVER voluntarily departed the United States under an order of removal? Select Yes | CheckBox |
Indicate whether you have ever voluntarily departed the United States under an order of removal. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. B. Have you EVER voluntarily departed the United States under an order of removal? Select No | CheckBox |
Indicate whether you have EVER voluntarily departed the United States under an order of removal.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. C. If you answered "Yes" to either Item Number 20. A. or 20.b. above, have you re-entered the United States unlawfully at any time after you were deported or you voluntarily departed? Select Yes | CheckBox |
If you answered 'Yes' to either Item Number 20.A. or 20.B., indicate whether you have re-entered the United States unlawfully at any time after you were deported or voluntarily departed.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. C. If you answered "Yes" to either Item Number 20. A. or 20.b. above, have you re-entered the United States unlawfully at any time after you were deported or you voluntarily departed? Select No | CheckBox |
If you answered 'Yes' to either Item Number 20.A. or 20.B., indicate whether you have re-entered the United States unlawfully at any time after you were deported or voluntarily departed.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. D. If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal? Select Yes | CheckBox |
If you answered 'Yes' to Item Number 20.C., indicate whether DHS has reinstated your prior order of removal.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. D. If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal? Select No | CheckBox |
If you answered 'Yes' to Item Number 20.C., indicate whether DHS has reinstated your prior order of removal.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. E. Have you EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability? Select Yes | CheckBox |
Indicate whether you have EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. E. Have you EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability? Select No | CheckBox |
Indicate whether you have EVER failed to attend or remain in attendance at any immigration proceedings to determine your admissibility or deportability.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 20. D. If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal? Select I Do Not Know | CheckBox |
If you answered 'Yes' to Item Number 20.C., indicate whether DHS has reinstated your prior order of removal. Select 'I Do Not Know' if you are unsure.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 21. Have you EVER, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other documentation, admission to the United States, or any other immigration benefit? Select Yes | CheckBox |
Indicate whether you have ever, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other documentation, admission to the United States, or any other immigration benefit. Select 'Yes' if applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 21. Have you EVER, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other documentation, admission to the United States, or any other immigration benefit? Select No | CheckBox |
Indicate whether you have ever, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other documentation, admission to the United States, or any other immigration benefit. Select 'No' if not applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. Part 7. Eligibility Standards. Human Rights Violations. If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred. 22. Have you EVER assisted any other person to enter the United States in violation of the law? Select Yes | CheckBox |
Indicate whether you have ever assisted any other person to enter the United States in violation of the law. Select 'Yes' if applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 22. Have you EVER assisted any other person to enter the United States in violation of the law? Select No | CheckBox |
Indicate whether you have ever assisted any other person to enter the United States in violation of the law. Select 'No' if not applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. A. Do you NOW have a communicable disease of public health significance? Select Yes | CheckBox |
Indicate whether you currently have a communicable disease of public health significance. Select 'Yes' if applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. A. Do you NOW have a communicable disease of public health significance? Select No | CheckBox |
Indicate whether you currently have a communicable disease of public health significance. Select 'No' if not applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. B. Do you NOW have or have you EVER had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others? Select Yes | CheckBox |
Indicate whether you currently have or have ever had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others. Select 'Yes' if applicable.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. B. Do you NOW have or have you EVER had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others? Select No | CheckBox |
Indicate whether you currently have or have ever had a physical or mental disorder with associated behavior that poses or may pose a threat to yourself or others. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. C. Are you NOW or have you EVER been a drug abuser or drug addict? Select Yes | CheckBox |
Indicate whether you are currently or have ever been a drug abuser or drug addict. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 23. C. Are you NOW or have you EVER been a drug abuser or drug addict? Select No | CheckBox |
Indicate whether you are currently or have ever been a drug abuser or drug addict. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 24. Have you EVER entered the United States as a stowaway? Select Yes | CheckBox |
Indicate whether you have ever entered the United States as a stowaway. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 24. Have you EVER entered the United States as a stowaway? Select No | CheckBox |
Indicate whether you have ever entered the United States as a stowaway. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 25. Did the former Immigration and Naturalization Service (I N S) EVER impose, or has DHS EVER imposed, civil monetary penalties on you for producing or using false documentation to obtain an immigration benefit? Select Yes | CheckBox |
Indicate whether the former Immigration and Naturalization Service (INS) or the Department of Homeland Security (DHS) has ever imposed civil monetary penalties on you for producing or using false documentation to obtain an immigration benefit. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 25. Did the former Immigration and Naturalization Service (I N S) EVER impose, or has DHS EVER imposed, civil monetary penalties on you for producing or using false documentation to obtain an immigration benefit? Select No | CheckBox |
Indicate whether the former Immigration and Naturalization Service (INS) or the Department of Homeland Security (DHS) has ever imposed civil monetary penalties on you for producing or using false documentation to obtain an immigration benefit. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 26. Are you NOW subject to a final order for violation of section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)? Select Yes | CheckBox |
Indicate whether you are currently subject to a final order for violation of section 274C, which involves producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 26. Are you NOW subject to a final order for violation of section 274C (producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)? Select No | CheckBox |
Indicate whether you are currently subject to a final order for violating section 274C, which involves producing and/or using false documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 27. Do you NOW practice polygamy? Select Yes | CheckBox |
Indicate whether you currently practice polygamy. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 27. Do you NOW practice polygamy? Select No | CheckBox |
Indicate whether you currently practice polygamy. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 28. Are you NOW the guardian of, and are you accompanying, another individual who has been found to be inadmissible and who has been certified by a medical examiner to be helpless due to sickness, physical or mental disability, or infancy? Select Yes | CheckBox |
Indicate whether you are currently the guardian of, and accompanying, another individual who has been found to be inadmissible and certified by a medical examiner to be helpless due to sickness, physical or mental disability, or infancy. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 28. Are you NOW the guardian of, and are you accompanying, another individual who has been found to be inadmissible and who has been certified by a medical examiner to be helpless due to sickness, physical or mental disability, or infancy? Select No | CheckBox |
Indicate whether you are currently the guardian of, and accompanying, another individual who has been found to be inadmissible and certified by a medical examiner to be helpless due to sickness, physical or mental disability, or infancy. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 18. C. Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution? Select Yes | CheckBox |
Indicate whether you have ever, within the past 10 years, received, in whole or in part, the proceeds of prostitution. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 18. C. Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution? Select No | CheckBox |
Indicate whether you have ever, within the past 10 years, received, in whole or in part, the proceeds of prostitution. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 18. B. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? 18. B. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? Select Yes | CheckBox |
Indicate whether you have ever, within the past 10 years, either directly or indirectly, procured or attempted to procure or import prostitutes or persons for the purpose of prostitution. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been.18. B. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? 18. B. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? Select No | CheckBox |
Indicate whether you have ever, within the past 10 years, directly or indirectly procured or attempted to procure or import prostitutes or persons for the purpose of prostitution. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 29. Have you EVER detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from a U.S. citizen granted custody? Select Yes | CheckBox |
Indicate whether you have ever detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from a U.S. citizen granted custody. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 29. Have you EVER detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from a U.S. citizen granted custody? Select No | CheckBox |
Indicate whether you have ever detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from a U.S. citizen granted custody. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. A. Acts involving torture or genocide? Select Yes | CheckBox |
Indicate whether you have ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving torture or genocide. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. A. Acts involving torture or genocide? Select No | CheckBox |
Indicate whether you have ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving torture or genocide. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. B. Killing any person? Select Yes | CheckBox |
Indicate whether you have ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in the killing of any person. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. B. Killing any person? Select No | CheckBox |
Indicate whether you have ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in the killing of any person. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. C. Intentionally and severely injuring any person? Select Yes | CheckBox |
Indicate whether you have ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in intentionally and severely injuring any person. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. C. Intentionally and severely injuring any person? Select No | CheckBox |
Indicate whether you have ever intentionally and severely injured any person. Select 'No' if you have not.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. D. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Select Yes | CheckBox |
Indicate whether you have ever engaged in any kind of sexual contact or relations with any person who was being forced or threatened. Select 'Yes' if you have.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. D. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Select No | CheckBox |
Indicate whether you have ever engaged in any kind of sexual contact or relations with any person who was being forced or threatened. Select 'No' if you have not.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. E. Limiting or denying any person's ability to exercise religious beliefs? Select Yes | CheckBox |
Indicate whether you have ever limited or denied any person's ability to exercise religious beliefs. Select 'Yes' if you have.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following. 30. E. Limiting or denying any person's ability to exercise religious beliefs? Select No | CheckBox |
Indicate whether you have ever limited or denied any person's ability to exercise religious beliefs. Select 'No' if you have not.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 16. Have you EVER been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Select Yes | CheckBox |
Indicate whether you have ever been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action. Select 'Yes' if you have.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 16. Have you EVER been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Select No | CheckBox |
Indicate whether you have ever been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action. Select 'No' if you have not.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 17. Have you EVER committed a serious criminal offense in the United States and asserted immunity from prosecution? Select Yes | CheckBox |
Indicate whether you have ever committed a serious criminal offense in the United States and asserted immunity from prosecution. Select 'Yes' if you have.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 17. Have you EVER committed a serious criminal offense in the United States and asserted immunity from prosecution? Select No | CheckBox |
Indicate whether you have ever committed a serious criminal offense in the United States and asserted immunity from prosecution. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 18. A. Have you EVER, within the past 10 years, or are you NOW engaged in prostitution or procurement of prostitution? Select Yes | CheckBox |
Indicate whether you have ever, within the past 10 years, or are currently engaged in prostitution or procurement of prostitution. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER, whether in the United States or any other country been. 18. A. Have you EVER, within the past 10 years, or are you NOW engaged in prostitution or procurement of prostitution? Select No | CheckBox |
Indicate whether you have ever, within the past 10 years, or are currently engaged in prostitution or procurement of prostitution. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 33. Have you EVER assisted with or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person? Select Yes | CheckBox |
Indicate whether you have ever assisted with or participated in selling or providing weapons to any person who you know used them against another person, or in transporting weapons to any person who you know used them against another person. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 33. Have you EVER assisted with or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person? Select No | CheckBox |
Indicate whether you have ever assisted with or participated in selling or providing weapons to any person who you know used them against another person, or in transporting weapons to any person who you know used them against another person. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 34. Have you EVER received any type of military, paramilitary, or weapons training? Select Yes | CheckBox |
Indicate whether you have ever received any type of military, paramilitary, or weapons training. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 34. Have you EVER received any type of military, paramilitary, or weapons training? Select No | CheckBox |
Indicate whether you have ever received any type of military, paramilitary, or weapons training. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 35. Have you EVER unlawfully voted in a United States Federal, state, or local election? Select Yes | CheckBox |
Indicate whether you have ever unlawfully voted in a United States Federal, state, or local election. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 35. Have you EVER unlawfully voted in a United States Federal, state, or local election? Select No | CheckBox |
Indicate whether you have ever unlawfully voted in a United States Federal, state, or local election. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 38. B. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? Select No | CheckBox |
Indicate whether you have EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 38. C. Are you NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses? Select Yes | CheckBox |
Indicate whether you are NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. 38. C. Are you NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses? Select No | CheckBox |
Indicate whether you are NOW the spouse or child of an alien who committed or conspired to commit human trafficking offenses by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 38. D. Are you NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? Select Yes | CheckBox |
Indicate whether you are NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 38. D. Are you NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? Select No | CheckBox |
Indicate whether you are NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 38. E. Within the previous five years, have you EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking? Select Yes | CheckBox |
Indicate whether within the previous five years, you have EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 38. E. Within the previous five years, have you EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking? Select No | CheckBox |
Indicate whether within the previous five years, you have EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit that you received resulted from such human trafficking by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 39. A. Are you NOW or have you EVER engaged in money laundering as described in section 1956 or 1957 of Title 18, United States Code? Select Yes | CheckBox |
Indicate whether you are NOW or have EVER engaged in money laundering as described in section 1956 or 1957 of Title 18, United States Code by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 39. A. Are you NOW or have you EVER engaged in money laundering as described in section 1956 or 1957 of Title 18, United States Code? Select No | CheckBox |
Indicate whether you are currently or have ever engaged in money laundering as described in section 1956 or 1957 of Title 18, United States Code. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 39. B. Are you NOW or have you EVER been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering? Select Yes | CheckBox |
Indicate whether you are currently or have ever been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 39. B. Are you NOW or have you EVER been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering? Select No | CheckBox |
Indicate whether you are currently or have ever been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 40. Have you EVER been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998 (22 U.S.C. section 6402) while serving as a foreign government official? Select Yes | CheckBox |
Indicate whether you have ever been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998, while serving as a foreign government official. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. 40. Have you EVER been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998 (22 U.S.C. section 6402) while serving as a foreign government official? Select No | CheckBox |
Indicate whether you have ever been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998, while serving as a foreign government official. Select 'No' if this does not apply to you.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 41. Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous asylum application in the past? Select Yes | CheckBox |
Indicate whether an immigration judge or the Board of Immigration Appeals has ever determined that you filed a frivolous asylum application in the past. Select 'Yes' if this applies to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 41. Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous asylum application in the past? Select No | CheckBox |
Indicate whether an immigration judge or the Board of Immigration Appeals has ever determined that you filed a frivolous asylum application in the past. Select 'No' if this does not apply to you.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 31. A. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Select Yes | CheckBox |
Select 'Yes' if you have ever served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 31. A. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? Select No | CheckBox |
Select 'No' if you have never served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 31. B. Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Select Yes | CheckBox |
Select 'Yes' if you have ever served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons.
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| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER. 31. B. Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Select No | CheckBox |
Select 'No' if you have never served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons.
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| Part 7. Eligibility Standards. Human Rights Violations. 32. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so? Select Yes | CheckBox |
Select 'Yes' if you have ever been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so.
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| Part 7. Eligibility Standards. Human Rights Violations. 32. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so? Select No | CheckBox |
Indicate whether you have ever been a member of, assisted in, or participated in any group, unit, or organization where you or others used or threatened to use any type of weapon against any person. Select 'No' if this does not apply to you.
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| Eligibility Standards - Human Rights Violations | ||
| Part 7. Eligibility Standards. Human Rights Violations. 36. Have you EVER claimed to be a U. S. citizen (in writing or in any other way)? Select Yes | CheckBox |
Indicate whether you have ever claimed to be a U.S. citizen in writing or in any other way by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. 36. Have you EVER claimed to be a U. S. citizen (in writing or in any other way)? Select No | CheckBox |
Indicate whether you have ever claimed to be a U.S. citizen in writing or in any other way by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. 37. A. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? Select Yes | CheckBox |
Indicate whether you have ever recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group by selecting 'Yes'.
|
| Part 7. Eligibility Standards. Human Rights Violations. 37. A. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? Select No | CheckBox |
Indicate whether you have ever recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. 37. B. Have you EVER used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat? Select Yes | CheckBox |
Indicate whether you have ever used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. 37. B. Have you EVER used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat? Select No | CheckBox |
Indicate whether you have ever used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat by selecting 'No'.
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| Part 7. Eligibility Standards. Human Rights Violations. 38. A. Have you EVER committed or conspired to commit human trafficking offenses, as defined in the section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States? Select Yes | CheckBox |
Indicate whether you have ever committed or conspired to commit human trafficking offenses, as defined in section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States by selecting 'Yes'.
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| Part 7. Eligibility Standards. Human Rights Violations. 38. A. Have you EVER committed or conspired to commit human trafficking offenses, as defined in the section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States? Select No | CheckBox |
Indicate whether you have ever committed or conspired to commit human trafficking offenses, as defined in section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States by selecting 'No'.
|
| Part 7. Eligibility Standards. Human Rights Violations. 38. B. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker? Select Yes | CheckBox |
Indicate whether you have ever knowingly aided, abetted, assisted, conspired, or colluded with a human trafficker by selecting 'Yes'.
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| Employment Authorization | ||
| Part 1. Type of Application (Select one). Are you also filing a request for employment authorization? 3. A. Select Yes, I am requesting an Employment Authorization Document (E. A. D), and I am filing Form I-7 65, Application for Employment Authorization, together with my Form I-8 21 | CheckBox |
Select this checkbox if you are requesting an Employment Authorization Document (EAD) and are filing Form I-765 along with your Form I-821.
|
| Part 1. Type of Application (Select one). Are you also filing a request for employment authorization? 3. B. Select No, I am not currently requesting an E. A. D | CheckBox |
Select this checkbox if you are not currently requesting an Employment Authorization Document (EAD).
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| Form Identification | ||
| PDF417BarCode1 | Text |
This is a barcode field used for form identification and processing. No input is required.
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| PDF417BarCode1 | Text |
This is a barcode field used for form identification and processing. No input is required from you.
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| Form Metadata | ||
| PDF417BarCode1 | Text |
This field contains a barcode for form identification and should not be edited.
|
| PDF417BarCode1 | Text |
This is a barcode field that contains encoded information about the form. No input is required.
|
| PDF417BarCode1 | Text |
This field contains a barcode that encodes specific information about the form, including the form type and version. It is automatically generated and should not be modified.
|
| PDF417BarCode1 | Text |
This field contains a barcode that encodes specific information about the form. No action is required from the user.
|
| PDF417BarCode1 | Text |
This is a barcode field that contains encoded information about the form. No action is required from you.
|
| PDF417BarCode1 | Text |
This is a barcode field that contains encoded information about the form. No input is required from you.
|
| PDF417BarCode1 | Text |
This is a barcode field that contains encoded information about the form.
|
| Form Processing | ||
| PDF417BarCode1 | Text |
This is a barcode used for processing the form. No action is required from you.
|
| PDF417BarCode1 | Text |
This is a barcode field used for form processing. No input is required.
|
| Former Spouse Information | ||
| 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 requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses or all of your children, please use the space provided in Part 11. Additional Information. Names of All Your Former Spouses (if any). First Marriage. 1. A. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of your first former spouse. Complete this section only if you are filing a late initial application for TPS.
|
| Former Spouses Information | ||
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 1. B. Enter Given Name (First Name) | Text |
Enter the given name (first name) of your first former spouse.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 1. C. Enter Middle Name | Text |
Enter the middle name of your first former spouse.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 2. Enter Nationalities of Former Spouse | Text |
Enter the nationalities of your first former spouse.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 4. Enter Date of Birth of Former Spouse. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of birth of your first former spouse in the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 5. Enter Date of Death if Former Spouse Deceased. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
If your first former spouse is deceased, enter the date of death in the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. Dates of Marriage to Former Spouse. 6. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of your marriage to your first former spouse in the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. Dates of Marriage to Former Spouse. 6. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of your marriage to your first former spouse in the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 7. Enter How Marriage Ended (for example, divorce, widowed, annulled) | Text |
Enter how your marriage to your first former spouse ended (e.g., divorce, widowed, annulled).
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 8. Did or does this former spouse have TPS (if known)? Select Yes | CheckBox |
Select 'Yes' if your first former spouse had or has TPS, if known.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 8. Did or does this former spouse have TPS (if known)? Select No | CheckBox |
Indicate whether your former spouse from your first marriage had Temporary Protected Status (TPS), if known. Select 'No' if they did not have TPS.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 8. Did or does this former spouse have TPS (if known)? Select I Don't Know | CheckBox |
Indicate whether your former spouse from your first marriage had Temporary Protected Status (TPS), if known. Select 'I Don't Know' if you are unsure.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. If yes, what dates did he or she have TPS (if known)? 9. A. Enter From Date. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
Enter the start date when your former spouse from your first marriage had Temporary Protected Status (TPS), if known. Use the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. If yes, what dates did he or she have TPS (if known)? 9. B. Enter To Date. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
Enter the end date when your former spouse from your first marriage had Temporary Protected Status (TPS), if known. Use the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. If yes, what dates did he or she have TPS (if known)? 9. C. Select Present | CheckBox |
Select 'Present' if your former spouse from your first marriage currently has Temporary Protected Status (TPS).
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. If yes, what dates did he or she have TPS (if known)? 9. D. Select I do not know the dates | CheckBox |
Select 'I do not know the dates' if you are unsure about the dates when your former spouse from your first marriage had Temporary Protected Status (TPS).
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 10. Is this former spouse currently applying for or re-registering for TPS (if known)? Select Yes | CheckBox |
Indicate whether your former spouse from your first marriage is currently applying for or re-registering for Temporary Protected Status (TPS), if known. Select 'Yes' if they are.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 10. Is this former spouse currently applying for or re-registering for TPS (if known)? Select No | CheckBox |
Indicate whether your former spouse from your first marriage is currently applying for or re-registering for Temporary Protected Status (TPS), if known. Select 'No' if they are not.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 10. Is this former spouse currently applying for or re-registering for TPS (if known)? Select I Do Not Know | CheckBox |
Indicate whether your former spouse from your first marriage is currently applying for or re-registering for Temporary Protected Status (TPS), if known. Select 'I Do Not Know' if you are unsure.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 11. A. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of your second former spouse, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 11. B. Enter Given Name (First Name) | Text |
Enter the given name (first name) of your second former spouse, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 11. C. Enter Middle Name | Text |
Enter the middle name of your second former spouse, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 12. Enter Nationalities of Former Spouse | Text |
Enter the nationalities of your second former spouse, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 14. Enter Date of Birth of Former Spouse. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of birth of your second former spouse in the format MM/DD/YYYY, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 15. Enter Date of Death if Former Spouse Deceased. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of death of your second former spouse in the format MM/DD/YYYY, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. Dates of Marriage to Former Spouse. 16. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the start date of your marriage to your second former spouse in the format MM/DD/YYYY, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. Dates of Marriage to Former Spouse. 16. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the end date of your marriage to your second former spouse in the format MM/DD/YYYY, if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 17. Enter How Marriage Ended (for example, divorce, widowed, annulled) | Text |
Enter how your marriage to your second former spouse ended (e.g., divorce, widowed, annulled), if applicable.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 18. Did or does this former spouse have TPS (if known)? Select Yes | CheckBox |
Indicate whether your second former spouse has or had Temporary Protected Status (TPS), if known. Select 'Yes' if they did.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 18. Did or does this former spouse have TPS (if known)? Select No | CheckBox |
Indicate whether your second former spouse has or had Temporary Protected Status (TPS), if known. Select 'No' if they did not.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 18. Did or does this former spouse have TPS (if known)? Select I Don't Know | CheckBox |
Indicate whether your second former spouse has or had Temporary Protected Status (TPS), if known. Select 'I Don't Know' if you are unsure.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. If yes, what dates did he or she have TPS (if known)? 19. A. Enter From Date. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
If your second former spouse had TPS, enter the start date of their TPS status. Use the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. If yes, what dates did he or she have TPS (if known)? 19. B. Enter To Date. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
If your second former spouse had TPS, enter the end date of their TPS status. Use the format MM/DD/YYYY.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. If yes, what dates did he or she have TPS (if known)? 19. C. Second Present | CheckBox |
If your second former spouse currently has TPS, select 'Present'.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. If yes, what dates did he or she have TPS (if known)? 19. D. Select I do not know the dates | CheckBox |
If your second former spouse had TPS but you do not know the dates, select 'I do not know the dates'.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 20. Is this former spouse currently applying for or re-registering for TPS (if known)? Select Yes | CheckBox |
Indicate whether your second former spouse is currently applying for or re-registering for TPS, if known. Select 'Yes' if they are.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 20. Is this former spouse currently applying for or re-registering for TPS (if known)? Select No | CheckBox |
Indicate whether your second former spouse is currently applying for or re-registering for TPS, if known. Select 'No' if they are not.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 20. Is this former spouse currently applying for or re-registering for TPS (if known)? Select I Do Not Know | CheckBox |
Indicate whether your second former spouse is currently applying for or re-registering for TPS. Select 'I Do Not Know' if you are unsure.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). First Marriage. 3. Enter A. Number of former spouse (if any and if known) | Text |
Enter the A-Number (Alien Number) of your first former spouse, if any and if known. This number is typically 9 digits long.
|
| Part 5. Information About Your Former Spouses (if any). Names of All Your Former Spouses (if any). Second Marriage. 13. Enter A-Number of former spouse (if any and if known) | Text |
Enter the A-Number (Alien Number) of your second former spouse, if any and if known. This number is typically 9 digits long.
|
| General Information | ||
| PDF417BarCode1 | Text |
This field contains a barcode that encodes specific information about the form and its version.
|
| Human Rights Violations | ||
| Part 7. Eligibility Standards. Human Rights Violations. If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred. Have you EVER been convicted of. 8. A. Any felony committed in the United States? Select Yes | CheckBox |
Select 'Yes' if you have ever been convicted of any felony committed in the United States.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 8. A. Any felony committed in the United States? Select No | CheckBox |
Select 'No' if you have never been convicted of any felony committed in the United States.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 8. B. Any misdemeanor committed in the United States? Select Yes | CheckBox |
Select 'Yes' if you have ever been convicted of any misdemeanor committed in the United States.
|
| Part 7. Eligibility Standards. Human Rights Violations. Have you EVER been convicted of. 8. B. Any misdemeanor committed in the United States? Select No | CheckBox |
Select 'No' if you have never been convicted of any misdemeanor committed in the United States.
|
| Information About Your Current Spouse | ||
| Part 4. Information About Your Current Spouse (if any). Complete this section only if you are filing a late initial application for T P S. See the form instructions for information on requirements for late initial filing for T P S. 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. Provide the following information about your current spouse (if married). 1. Enter U S C I S Online Account Number, (if any and if known) | Text |
Enter your USCIS Online Account Number if you have one and know it. This is required if you are filing a late initial application for TPS.
|
| Part 4. Information About Your Current Spouse (if any). 3. A. Enter Family Name (Last Name) | Text |
Enter the family name (last name) of your current spouse.
|
| Internal Use | ||
| PDF417BarCode1 | Text |
This is a barcode field used for internal processing by the Department of Homeland Security. No input is required from you.
|
| Interpreter Information | ||
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Full Name. 1. A. Enter Interpreter's Family Name (Last Name) | Text |
Enter the interpreter's family name (last name) who is assisting you with this form.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Full Name. 1. B. Enter Interpreter's Given Name (First Name) | Text |
Enter the interpreter's given name (first name) who is assisting you with this form.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Full Name. 2. Enter Interpreter's Business or Organization Name (if any) | Text |
Enter the name of the business or organization the interpreter is associated with, if any.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. A. Enter Street Number and Name | Text |
Enter the street number and name of the interpreter's mailing address.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. B. Select Apartment | CheckBox |
Select this checkbox if the interpreter's mailing address includes an apartment number.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. B. Select Suite | CheckBox |
Select this checkbox if the interpreter's mailing address includes a suite number.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. B. Select Floor | CheckBox |
Select this checkbox if the interpreter's mailing address includes a floor number.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the interpreter's mailing address.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Interpreter's Signature. 7. A. Interpreter's Signature. This signature field can not be signed with a digital signature and the signee's name can not be typewritten into this space. This is a protected field. Print and sign in ink | Text |
This field is for the interpreter's signature. The interpreter must print and sign their name in ink. Digital signatures and typewritten names are not allowed.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Interpreter's Signature. 7. B. Enter Date of Signature. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
Enter the date when the interpreter signed the form. Use the format MM/DD/YYYY.
|
| Interpreter's Contact Information | ||
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. C. Enter City or Town | Text |
Enter the city or town of the interpreter's mailing address.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. D. Select State from a List of States | ComboBox |
Select the state from the provided list for the interpreter's mailing address.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. E. Enter ZIP Code | Text |
Enter the ZIP code of the interpreter's mailing address. The ZIP code should be 5 digits long.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. F. Enter the Province | Text |
Enter the province of the interpreter's mailing address.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. G. Enter the Postal Code | Text |
Enter the postal code of the interpreter's mailing address. The postal code can be up to 9 characters long.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Mailing Address. 3. H. Enter the Country | Text |
Enter the country of the interpreter's mailing address.
|
| Interpreter's Information | ||
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Contact Information. 4. Enter Interpreter's Daytime Telephone Number | Text |
Enter the daytime telephone number of the interpreter, including the area code.
|
| Part 9. Interpreter's Certification, Signature, and Contact Information. Provide the following information concerning the interpreter. Interpreter's Contact Information. 6. Enter Interpreter's Email Address (if any) | Text |
Enter the email address of the interpreter, if available.
|
| Part 9. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Contact Information. 5. Enter Interpreter's Mobile Telephone Number (if any) | Text |
Enter the mobile telephone number of the interpreter, if available, including the area code.
|
| Part 6. Interpreter's Certification, Signature, and Contact Information. Interpreter's Certification. I certify, under penalty of perjury, that I am fluent in English and which is the same language specified in Part 8., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer. Enter Language | Text |
Enter the language in which you are fluent and used to interpret the application for the applicant.
|
| Mailing Address | ||
| Part 2. Information About You. U. S. Mailing Address. 4. A. Enter In Care Of Name | Text |
Enter the name of the person in whose care your mail should be sent.
|
| Part 2. Information About You. U. S. Mailing Address. 4. B. Enter Street Number and Name | Text |
Enter the street number and name of your U.S. mailing address.
|
| Part 2. Information About You. U. S. Mailing Address. 4. C. Select Apartment | CheckBox |
Select this checkbox if your U.S. mailing address includes an apartment.
|
| Part 2. Information About You. U. S. Mailing Address. 4. C. Select Suite | CheckBox |
Select this checkbox if your U.S. mailing address includes a suite.
|
| Part 2. Information About You. U. S. Mailing Address. 4. C. Select Floor | CheckBox |
Select this checkbox if your U.S. mailing address includes a floor.
|
| Part 2. Information About You. U. S. Mailing Address. 4. C. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of your U.S. mailing address.
|
| Part 2. Information About You. U. S. Mailing Address. 4. D. Enter City or Town | Text |
Enter the city or town of your U.S. mailing address.
|
| Part 2. Information About You. U. S. Mailing Address. 4. F. Enter ZIP Code | Text |
Enter the ZIP Code for your U.S. mailing address. This should be a 5-digit number.
|
| Part 2. Information About You. U. S. Mailing Address. 5. Is your current mailing address the same as your physical address (where you live)? Select Yes | CheckBox |
Select 'Yes' if your current mailing address is the same as your physical address.
|
| Part 2. Information About You. U. S. Mailing Address. 5. Is your current mailing address the same as your physical address (where you live)? Select No. If you answered "No" to Item Number 5., please provide your physical address below | CheckBox |
Select 'No' if your current mailing address is different from your physical address. If you select 'No', you will need to provide your physical address below.
|
| Marital Information | ||
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Single, never married | CheckBox |
Select this checkbox if your current marital status is 'Single, never married'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Married | CheckBox |
Select this checkbox if your current marital status is 'Married'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Divorced | CheckBox |
Select this checkbox if your current marital status is 'Divorced'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Widowed | CheckBox |
Select this checkbox if your current marital status is 'Widowed'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Separated | CheckBox |
Select this checkbox if your current marital status is 'Separated'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Marriage Annulled | CheckBox |
Select this checkbox if your current marital status is 'Marriage Annulled'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Select Other | CheckBox |
Select this checkbox if your current marital status is 'Other'. Only one marital status option should be selected.
|
| Part 2. Information About You. Your Marital Information. 17. Current Marital Status (Select only one box). Specify Other | Text |
If you selected 'Other' for your current marital status, specify your marital status here.
|
| Part 2. Information About You. Your Marital Information. 18. Enter Date of Current Marriage (if currently married). Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of your current marriage if you are currently married. Use the format MM/DD/YYYY.
|
| Other Dates of Birth Used | ||
| Part 2. Information About You. Other Dates of Birth Used (if any). 11. B. Enter Other Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter any other date of birth you have used in the format MM/DD/YYYY (2-digit month, 2-digit day, and 4-digit year).
|
| Part 2. Information About You. 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. Enter Other Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Provide all other dates of birth you have ever used in the format MM/DD/YYYY (2-digit month, 2-digit day, and 4-digit year). If you need extra space, use the space provided in Part 11. Additional Information.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 12. Gender. Select Male | CheckBox |
Select this checkbox if your gender is Male.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 12. Gender. Select Female | CheckBox |
Select this checkbox if your gender is Female.
|
| Other Information | ||
| Part 2. Information About You. Other Information. 8. Enter U S C I S Online Account Number (if any) | Text |
Enter your USCIS Online Account Number if you have one. This number can be up to 12 characters long.
|
| Part 2. Information About You. Other Information. 10. Enter Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter your date of birth in the format MM/DD/YYYY (2-digit month, 2-digit day, and 4-digit year).
|
| Part 2. Information About You. Other Information. 7. Enter Alien Registration Number (A. Number) (if any) | Text |
Enter your Alien Registration Number (A. Number) if you have one. This number is typically 9 digits long.
|
| Personal Information | ||
| Part 2. Information About You. Your Full Name. 1. A. Enter Family Name (Last Name) | Text |
Enter your family name (last name) as it appears on official documents.
|
| Part 2. Information About You. Your Full Name. 1. B. Enter Given Name (First Name) | Text |
Enter your given name (first name) as it appears on official documents.
|
| Part 2. Information About You. Your Full Name. 1. C. Enter Middle Name | Text |
Enter your middle name as it appears on official documents. If you do not have a middle name, leave this field blank.
|
| Part 2. Information About You. Other Names Used. 3. A. Enter Family Name (Last Name) | Text |
Enter any other family names (last names) you have used since birth, including aliases, maiden names, and nicknames.
|
| Part 2. Information About You. Other Names Used. 3. B. Enter Given Name (First Name) | Text |
Enter any other given names (first names) you have used since birth, including aliases, maiden names, and nicknames.
|
| Part 2. Information About You. Other Names Used. 3. C. Enter Middle Name | Text |
Enter any other middle names you have used since birth, including aliases, maiden names, and nicknames.
|
| Part 2. Information About You. Other Names Used. Provide 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. Enter Family Name (Last Name) | Text |
Enter any other family names (last names) you have used since birth, including aliases, maiden names, and nicknames. If you need extra space, use the space provided in Part 11. Additional Information.
|
| Part 2. Information About You. Other Names Used. 2. B. Enter Given Name (First Name) | Text |
Enter your given name (first name) if you have used any other names.
|
| Part 2. Information About You. Other Names Used. 2. C. Enter Middle Name | Text |
Enter your middle name if you have used any other names.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 13. Enter City/Town/Village of Birth | Text |
Enter the city, town, or village where you were born. If you have used other dates of birth, provide this information as well.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 14. Enter Country of Birth | Text |
Enter the country where you were born. If you have used other dates of birth, provide this information as well.
|
| Part 2. Information About You. Other Information. 9. Enter U. S. Social Security Number (if any) | Text |
Enter your U.S. Social Security Number if you have one. This is a 9-digit number issued by the Social Security Administration.
|
| Part 11. Additional Information. 2. A. Number (if any). (This field is pre-populated from Part 1.) | Text |
Enter your Alien Number if you have one. This field is pre-populated from Part 1 of the form.
|
| Physical Address | ||
| Part 2. Information About You. Physical Address. 4. E. Select State from a List of States | ComboBox |
Select the state of your physical address from the provided list.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
|
| Part 2. Information About You. U. S. Physical Address. 6. A. Enter Street Number and Name | Text |
Enter the street number and name for your U.S. physical address. This can be up to 34 characters long.
|
| Part 2. Information About You. U. S. Physical Address. 6. B. Select Apartment | CheckBox |
Select this checkbox if your physical address includes an apartment number.
|
| Part 2. Information About You. U. S. Physical Address. 6. B. Select Suite | CheckBox |
Select this checkbox if your physical address includes a suite number.
|
| Part 2. Information About You. U. S. Physical Address. 6. B. Select Floor | CheckBox |
Select this checkbox if your physical address includes a floor number.
|
| Part 2. Information About You. U. S. Physical Address. 6. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number for your U.S. physical address. This can be up to 6 characters long.
|
| Part 2. Information About You. U. S. Physical Address. 6. C. Enter City or Town | Text |
Enter the city or town for your U.S. physical address. This can be up to 20 characters long.
|
| Preparer Information | ||
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Full Name. 1. A. Enter Preparer's Family Name (Last Name) | Text |
Enter the last name (family name) of the person who prepared this application, if it is someone other than the applicant.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Full Name. 1. B. Enter Preparer's Given Name (First Name) | Text |
Enter the first name (given name) of the person who prepared this application, if it is someone other than the applicant.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Full Name. 2. Enter Preparer's Business or Organization Name (if any) | Text |
Enter the business or organization name of the person who prepared this application, if applicable.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. A. Enter Street Number and Name | Text |
Enter the street number and name of the mailing address of the person who prepared this application.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. B. Select Apartment | CheckBox |
Select this checkbox if the preparer's mailing address includes an apartment number.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. B. Select Suite | CheckBox |
Select this checkbox if the preparer's mailing address includes a suite number.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. B. Select Floor | CheckBox |
Select this checkbox if the preparer's mailing address includes a floor number.
|
| Preparer's Contact Information | ||
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Contact Information. 4. Preparer's Daytime Telephone Number. Enter the telephone number including the area code or country code | Text |
Enter the preparer's daytime telephone number, including the area code or country code.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Contact Information. 5. Preparer's Mobile Telephone Number (if any). Enter the telephone number including the area code or country code | Text |
Enter the mobile telephone number of the person who prepared this application, including the area code or country code.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Contact Information. 6. Enter Preparer's Email Address | Text |
Enter the email address of the person who prepared this application.
|
| Preparer's Mailing Address | ||
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the preparer's mailing address.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. C. Enter City or Town | Text |
Enter the city or town of the preparer's mailing address.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. D. Select State from a List of States | ComboBox |
Select the state from the provided list for the preparer's mailing address.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. E. Enter ZIP Code | Text |
Enter the ZIP code of the preparer's mailing address.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. F. Enter the Province | Text |
Enter the province of the preparer's mailing address, if applicable.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. G. Enter the Postal Code | Text |
Enter the postal code of the preparer's mailing address.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Mailing Address. 3. H. Enter the Country | Text |
Enter the country of the preparer's mailing address.
|
| Preparer's Signature | ||
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Signature. 8. A. Preparer's Signature. This form can not be signed electronically. The name of the preparer can not be typewritten into this space | Text |
Provide the signature of the person preparing this application. Note that this form cannot be signed electronically and the name of the preparer cannot be typewritten into this space.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Signature. 8. B. Enter Date of Signature. Enter as 2 digit month, 2 digit day and 4 digit year | Text |
Enter the date of the preparer's signature in the format MM/DD/YYYY.
|
| Preparer's Statement | ||
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Statement. 7. A. Select I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent | CheckBox |
Select this checkbox if you are not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Statement. 7. B. Select I am an attorney or accredited representative. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States with this application | CheckBox |
Select this checkbox if you are an attorney or accredited representative. Note that if your representation extends beyond the preparation of this application, you may need to submit a completed Form G-28 or G-28I with this application.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Statement. 7. B. Select I am an attorney or accredited representative and my representation of the applicant in this case extends beyond the preparation of this application | CheckBox |
Select this checkbox if you are an attorney or accredited representative and your representation of the applicant extends beyond the preparation of this application.
|
| Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Provide the following information concerning the preparer. Preparer's Statement. 7. B. Select I am an attorney or accredited representative and my representation of the applicant in this case does not extend beyond the preparation of this application | CheckBox |
Select this checkbox if you are an attorney or accredited representative and your representation of the applicant does not extend beyond the preparation of this application.
|
| Residency History | ||
| Part 2. Information About You. Other Dates of Birth Used (if any). 15. A. Enter Countries of Residence (Before entering the U.S.) | Text |
List the countries where you resided before entering the United States. This information is used to understand your residency history.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 15. B. Enter Countries of Residence (Before entering the U.S.) | Text |
List the countries where you resided before entering the United States. This information is used to understand your residency history.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 15. C. Enter Countries of Residence (Before entering the U.S.) | Text |
List the countries where you resided before entering the United States. This information is used to understand your residency history.
|
| Part 2. Information About You. Other Dates of Birth Used (if any). 15. D. Enter Countries of Residence (Before entering the U.S.) | Text |
List the countries where you resided before entering the United States. This information is used to understand your residency history.
|
| Spouse Information | ||
| Part 4. Information About Your Current Spouse (if any). 3. B. Enter Given Name (First Name) | Text |
Enter the given name (first name) of your current spouse, if applicable.
|
| Part 4. Information About Your Current Spouse (if any). 3. C. Enter Middle Name | Text |
Enter the middle name of your current spouse, if applicable.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 8. A. Enter City or Town | Text |
Enter the city or town where your current spouse resides.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 8. C. Enter the Province (if any) | Text |
Enter the province where your current spouse resides, if applicable. Maximum length is 20 characters.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 8. D. Enter the Country | Text |
Enter the country where your current spouse resides.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 9. If you know, has your current spouse EVER had TPS? Select Yes | CheckBox |
Select 'Yes' if your current spouse has ever had Temporary Protected Status (TPS).
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 9. If you know, has your current spouse EVER had TPS? Select No | CheckBox |
Select 'No' if your current spouse has never had Temporary Protected Status (TPS).
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. If yes, what dates did he or she have T P S? 10. A. Enter From Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
If your current spouse has had TPS, enter the start date of the TPS period in the format MM/DD/YYYY.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. If yes, what dates did he or she have T P S? 10. B. Enter To Date. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
If your current spouse has had TPS, enter the end date of the TPS period in the format MM/DD/YYYY.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. If yes, what dates did he or she have T P S? 10. C. Select Present | CheckBox |
Select this option if your current spouse's TPS status is still present.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. If yes, what dates did he or she have T P S? 10. D. Select I do not know the dates | CheckBox |
Select this option if you do not know the dates of your current spouse's TPS period.
|
| Spouse Mailing Address | ||
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. A. Enter Street Number and Name | Text |
Enter the street number and name of the mailing address of your current spouse.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. B. Select Apartment | CheckBox |
Select this checkbox if the mailing address of your current spouse includes an apartment.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. B. Select Suite | CheckBox |
Select this checkbox if the mailing address of your current spouse includes a suite.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. B. Select Floor | CheckBox |
Select this checkbox if the mailing address of your current spouse includes a floor.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. B. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the mailing address of your current spouse.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. C. Enter City or Town | Text |
Enter the city or town of the mailing address of your current spouse.
|
| Spouse's Information | ||
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 5. Enter Your Spouse's Date of Birth. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter your current spouse's date of birth in the format MM/DD/YYYY.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 6. Enter Date of Marriage to Your Current Spouse. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of your marriage to your current spouse in the format MM/DD/YYYY.
|
| Part 4. Information About Your Current Spouse (if any). Other Information About Your Current Spouse. 7. Enter Place of Marriage to Your Current Spouse | Text |
Enter the place where you got married to your current spouse.
|
| Spouse's Mailing Address | ||
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. D. Select State from a List of States | ComboBox |
Select the state from the provided list where your current spouse's mailing address is located.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. E. Enter ZIP Code | Text |
Enter the ZIP code of your current spouse's mailing address. The ZIP code should be 5 digits long.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. F. Enter the Province | Text |
Enter the province of your current spouse's mailing address. The province name should not exceed 20 characters.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. G. Enter the Postal Code | Text |
Enter the postal code of your current spouse's mailing address. The postal code should not exceed 9 characters.
|
| Part 4. Information About Your Current Spouse (if any). Mailing Address of Spouse. 4. H. Enter the Country | Text |
Enter the country of your current spouse's mailing address.
|
| U.S. Entry Information | ||
| Part 2. Information About You. U.S. Entry Information. 19. Enter Date of Last Entry into the United States. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date of your last entry into the United States. Use the format MM/DD/YYYY.
|
| Part 2. Information About You. U.S. Entry Information. 20. Enter Immigration Status (or Lack of Status) When You Last Entered the United States (for example, visitor, student, no status) | Text |
Enter your immigration status (or lack of status) at the time of your last entry into the United States. Examples include visitor, student, or no status.
|
| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 21. Enter U.S. Port of Entry (if any) | Text |
Enter the U.S. port of entry where you last entered the United States, if applicable.
|
| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 22. A. Enter City or Town | Text |
Enter the city or town of your last entry into the United States.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 22. B. Select State from a List of States | ComboBox |
Select the state from the list where you last entered the United States.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 24. Enter Date Your Authorized Period of Stay in the United States Expired or Will Expire (as shown on Form I-94 or Crewman's Landing Permit (Form I-95)) (mm/dd/yyyy or duration of status (D/S). Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the date your authorized period of stay in the United States expired or will expire, as shown on Form I-94 or Crewman's Landing Permit (Form I-95). Use the format MM/DD/YYYY or enter 'D/S' for duration of status.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 25. Enter Passport Number (most recent passport) (if any) (If you have other expired or valid passports, please list all of them and provide all information requested below about each passport.) | Text |
Enter the number of your most recent passport. If you have other expired or valid passports, list all of them and provide the requested information for each.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 27. Enter Additional Passport or Travel Document Number | Text |
Enter the additional passport or travel document number you used when you last entered the United States.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 28. Enter Additional Passport or Travel Document Number | Text |
Enter another additional passport or travel document number you used when you last entered the United States.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 29. Enter Country of Issuance for most recent Passport or Travel Document | Text |
Enter the country that issued your most recent passport or travel document.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 30. Enter Expiration Date for most recent Passport or Travel Document. Enter as 2-digit Month, 2-digit Day, and 4-digit Year | Text |
Enter the expiration date of your most recent passport or travel document in the format MM/DD/YYYY.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 26. Enter Travel Document Number (if any) | Text |
Enter the travel document number, if you have one, that you used when you last entered the United States.
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| Part 2. Information About You. U.S. Entry Information. Place of Last Entry into the United States. 23. Enter the I 94 Arrival Departure record number (if any) | Text |
Enter your I-94 Arrival/Departure record number, if available.
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| U.S. Physical Address | ||
| Part 2. Information About You. U.S. Physical Address. 6. D. Select State from a List of States | ComboBox |
Select the state where your U.S. physical address is located from the provided list of states.
WV
KY
NY
VA
IN
MD
NH
AP
VT
WA
RI
AR
MT
WY
MI
TN
WI
ID
IA
FL
SD
NE
MA
MS
SC
MN
MH
AA
GA
NJ
MP
TX
NM
VI
KS
OR
HI
MO
GU
IL
OH
DC
AE
PR
AL
AK
PW
LA
NV
CO
DE
NC
OK
ND
PA
AZ
UT
AS
FM
CT
CA
ME
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| Part 2. Information About You. U. S. Physical Address. 6. E. Enter ZIP Code | Text |
Enter the ZIP Code for your U.S. physical address. The ZIP Code should be exactly 5 digits long.
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