Form I-821D 04/24/19
To Be Completed by an Attorney or
Accredited Representative, if any.
For
USCIS
Use
Only
Sent: / / /
Consideration of Deferred Action
for Childhood Arrivals
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-821D
OMB No. 1615-0124
Expires 04/30/2021
Attorney State Bar Number (if any):
Action BlockReceipt
Remarks
Resubmitted: / / /
Returned: / / /
Case ID:
Relocated
Requestor interviewed
on
Select this box if Form G-28 is attached to
represent the requestor.
Received: / / /
START HERE - Type or print in black ink. Read Form I-821D Instructions for information on how to complete this form.
A-
Part 1. Information About You (For Initial and
Renewal Requests)
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
Middle Name
Full Legal Name
For this Renewal request, my most recent period of Deferred
Action for Childhood Arrivals expires on
I am requesting:
(mm/dd/yyyy)
Initial Request - Consideration of Deferred Action
for Childhood Arrivals
Renewal Request - Consideration of Deferred
Action for Childhood Arrivals
I am not in immigration detention and I have included Form
I-765, Application for Employment Authorization, and Form
I-765WS, Form I-765 Worksheet; and
1.
2.
U.S. Mailing Address (Enter the same address on
Form I-765)
4.a.
In Care Of Name (if applicable)
Street Number
and Name
4.b.
4.c.
Flr.Ste.
Apt.
OR
AND
Removal Proceedings Information
Are you NOW or have you EVER been in removal
proceedings, or do you have a removal order issued in any
other context (for example, at the border or within the
United States by an immigration agent)?
5.
Yes No
NOTE: The term “removal proceedings” includes
exclusion or deportation proceedings initiated before
April 1, 1997; an Immigration and Nationality Act (INA)
section 240 removal proceeding; expedited removal;
reinstatement of a final order of exclusion, deportation, or
removal; an INA section 217 removal after admission
under the Visa Waiver Program; or removal as a criminal
alien under INA section 238.
Currently in Proceedings (Active)
Currently in Proceedings (Administratively Closed)
Terminated
Subject to a Final Order
5.f. Most Recent Date of Proceedings
5.a.
5.b.
5.c.
5.d.
Status or outcome:
If you answered "Yes" to Item Number 5., you must select a
box below indicating your current status or outcome of your
removal proceedings.
5.g. Location of Proceedings
(mm/dd/yyyy)
Other. Explain in Part 8. Additional Information.
5.e.
ZIP Code
4.f.
State
4.e.
City or Town4.d.
Page 1 of 7
Form I-821D 04/24/19
Other Information
Current Country of Residence11.
Country of Citizenship or Nationality
Marital Status
12.
SingleMarried DivorcedWidowed
13.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Other Names Used (If Applicable)
14.a.
14.b.
14.c.
If you need additional space, use Part 8. Additional
Information.
8.
Gender
Male Female
Date of Birth (mm/dd/yyyy)
10.a.
City/Town/Village
of Birth
9.
Country of Birth 10.b.
A-
Alien Registration Number (A-Number) (if any)6.
7.
U.S. Social Security Number (if any)
Part 1. Information About You (For Initial and
Renewal Requests) (continued)
Hair Color (Select only one box) 20.
Black
Brown Red
White
Unknown/
Other
Sandy
Gray
BlondBald (No hair)
Height
18. Weight Pounds
Feet Inches
17.
Black Brown
Green
Maroon Pink
HazelGray
Blue
19.
Eye Color (Select only one box)
Unknown/Other
Part 2. Residence and Travel Information (For
Initial and Renewal Requests)
1.
I have been continuously residing in the U.S. since at least
June 15, 2007, up to the present time.
Yes No
For Renewal Requests: List only the addresses where you
resided since you submitted your last Form I-821D that was
approved.
For Initial Requests: List your current address and, to the best
of your knowledge, the addresses where you resided since the
date of your initial entry into the United States to present.
If you require additional space, use Part 8. Additional
Information.
16.
Race (Select all applicable boxes)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Asian
Black or African American
Processing Information
15.
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select only one box)
NOTE: If you departed the United States for some period of
time before your 16th birthday and returned to the United States
on or after your 16th birthday to begin your current period of
continuous residence, and if this is an initial request, submit
evidence that you established residence in the United States prior
to 16 years of age as set forth in the instructions to this form.
Page 2 of 7
Form I-821D 04/24/19
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
Street Number
and Name
3.a.
3.b.
Address 1
Dates at this residence (mm/dd/yyyy)
From
To
3.f.
Flr.Ste.
Apt.
2.c.
City or Town
2.d.
State
2.e.
ZIP Code
Street Number
and Name
2.a.
2.b.
Present Address
Dates at this residence (mm/dd/yyyy)
From
To
Present
2.f.
Flr.Ste.
Apt.
Part 2. Residence and Travel Information (For
Initial and Renewal Requests) (continued)
4.c.
City or Town
4.d.
State
4.e.
ZIP Code
Street Number
and Name
4.a.
4.b.
Address 2
Dates at this residence (mm/dd/yyyy)
From
To
4.f.
Flr.Ste.
Apt.
7.a.
7.b.
Reason for Departure
(mm/dd/yyyy)Departure Date
(mm/dd/yyyy)Return Date
7.c.
Departure 2
8. Have you left the United States without advance parole on
or after August 15, 2012?
Yes
No
What country issued your last passport?
9.a.
Passport Number9.b.
9.c.
(mm/dd/yyyy)
Passport Expiration Date
Border Crossing Card Number (if any)
10.
Departure 1
6.a.
6.b.
Reason for Departure
(mm/dd/yyyy)Departure Date
(mm/dd/yyyy)Return Date
6.c.
Travel Information
For Initial Requests: List
all of your absences from the United
States since June 15, 2007.
If you require additional space, use Part 8. Additional
Information.
For Renewal Requests: List only
your absences from the
United States
since you submitted your last Form I-821D that
was approved.
City or Town
5.d.
State
5.e.
ZIP Code
5.f.
5.c.
Street Number
and Name
5.a.
5.b.
Address 3
Dates at this residence (mm/dd/yyyy)
From To
Flr.Ste.Apt.
I initially arrived and established residence in the U.S.
prior to 16 years of age.
Part 3. For Initial Requests Only
1.
Yes No
(mm/dd/yyyy)
Date of Initial Entry into the United States (on or about)
2.
Place of Initial Entry into the United States3.
Page 3 of 7
Form I-821D 04/24/19
Immigration Status on June 15, 2012 (e.g., No Lawful
Status, Status Expired, Parole Expired)
4.
If you answered "Yes" to Item Number 5.a., provide the
date your authorized stay expired, as shown on Form I-94,
I-94W, or I-95 (if available).
(mm/dd/yyyy)
5.c.
Were you EVER issued an Arrival-Departure Record
(Form I-94, I-94W, or I-95)?
5.a.
Yes No
If you answered "Yes" to Item Number 5.a., provide
your Form I-94, I-94W, or I-95 number (if available).
5.b.
6. Indicate how you meet the education guideline (e.g.,
Graduated from high school, Received a general
educational development (GED) certificate or equivalent
state-authorized exam, Currently in school)
7. Name, City, and State of School Currently Attending or
Where Education Received
(mm/dd/yyyy)
Date of Graduation (e.g., Receipt of a Certificate of
Completion, GED certificate, other equivalent state-
authorized exam) or, if currently in school, date of last
attendance.
8.
Education Information
Service Start Date (mm/dd/yyyy)
(mm/dd/yyyy)Discharge Date
Type of Discharge
9.b.
9.c.
9.d.
Military Service Information
9. Were you a member of the U.S. Armed Forces or U.S.
Coast Guard?
Yes
No
Military Branch
9.a.
If you answered "Yes" to Item Number 9., you must provide
responses to Item Numbers 9.a. - 9.d.
Have you EVER engaged in, do you continue to engage
in, or plan to engage in terrorist activities?
NoYes
3.
Are you NOW or have you EVER been a member of a
gang?
NoYes
4.
If you answered "Yes," you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest.
1.
Have you EVER been arrested for, charged with, or
convicted of a felony or misdemeanor, including incidents
handled in juvenile court, in the United States? Do not
include minor traffic violations unless they were alcohol-
or drug-related.
Yes No
Part 4. Criminal, National Security, and Public
Safety Information (For Initial and Renewal
Requests)
If any of the following questions apply to you, use Part 8.
Additional Information to describe the circumstances and
include a full explanation.
If you answered “Yes,” you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest, unless
disclosure is prohibited under state law.
Have you EVER been arrested for, charged with, or
convicted of a crime in any country other than the United
States?
Yes No
2.
Part 3. For Initial Requests Only (continued)
Acts involving torture, genocide, or human trafficking?
Killing any person?
Yes No
Have you EVER engaged in, ordered, incited, assisted, or
otherwise
participated in any of the following:
Yes No
5.a.
Severely injuring any person?
Yes No
Any kind of sexual contact or relations with any person
who was being forced or threatened?
Yes No
5.b.
5.c.
5.d.
5.
Have you EVER recruited, enlisted, conscripted, or used
any person to serve in or help an armed force or group
while such person was under age 15?
6.
NoYes
Have you EVER used any person under age 15 to take
part in hostilities, or to help or provide services to people
in combat?
7.
NoYes
Page 4 of 7
Form I-821D 04/24/19
1.b. The interpreter named in Part 6. has read to me each
and every question and instruction on this form, as
well as my answer to each question, in
a language in which I am fluent. I understand each
and every question and instruction on this form as
translated to me by my interpreter, and have provided
true and correct responses in the language indicated
above.
,
(mm/dd/yyyy)Date of Signature2.b.
Requestor's Signature2.a.
Requestor's Certification
I certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct and that
copies of documents submitted are exact photocopies of
unaltered original documents. I understand that I may be
required to submit original documents to U.S. Citizenship and
Immigration Services (USCIS) at a later date. I also understand
that knowingly and willfully providing materially false
information on this form is a federal felony punishable by a
fine, imprisonment up to 5 years, or both, under 18 U.S.C.
section 1001. Furthermore, I authorize the release of any
information from my records that USCIS may need to reach a
determination on my deferred action request.
Part 5. Statement, Certification, Signature, and
Contact Information of the Requestor (For Initial
and Renewal Requests)
I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to each question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b.
Requestor's Daytime Telephone Number3.
Requestor's Contact Information
Requestor's Email Address5.
Requestor's Mobile Telephone Number4.
Interpreter's Business or Organization Name (if any)2.
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
3.g.
Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
Postal Code
Interpreter's Given Name (First Name)
1.b.
Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests)
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information concerning the interpreter:
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address5.
Page 5 of 7
Form I-821D 04/24/19
Preparer's Business or Organization Name2.
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
If Other than the Requestor (For Initial and
Renewal Requests)
(mm/dd/yyyy)Date of Signature6.b.
Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests) (continued)
Interpreter's Certification
I certify that:
is the same language provided in Part 5., Item Number 1.b.;
I am fluent in English and which
Interpreter's Signature6.a.
I have read to this requestor each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 5., Item Number 1.b.; and
The requestor has informed me that he or she understands each
and every instruction and question on the form, as well as the
answer to each question.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address
5. Preparer's Fax Number
7.a. Preparer's Signature
7.b. Date of Signature (mm/dd/yyyy)
Preparer's Declaration
I declare that I prepared this Form I-821D at the requestor's
behest, and it is based on all the information of which I have
knowledge.
NOTE: If you need extra space to complete any item within
this request, see the next page for Part 8. Additional
Information.
Preparer's Mailing Address
3.c.
3.d.
3.a.
3.b.
3.h.
3.f.
3.g.
City or Town
State 3.e. ZIP Code
Province
Street Number
and Name
Country
Apt.
Flr.Ste.
Postal Code
Page 6 of 7
Form I-821D 04/24/19
Part 8. Additional Information (For Initial and
Renewal Requests)
If you need extra space to complete any item within this
request, use the space below. You may also make copies of this
page to complete and file with this request. Include your name
and A-Number (if any) at the top of each sheet of paper;
indicate the Page Number, Part Number, and Item Number
to which your answer refers; and sign and date each sheet.
3.a. Page Number
3.b. Part Number 3.c. Item Number
3.d.
4.a.
Page Number
4.b.
Part Number
4.c.
Item Number
4.d.
Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
A-
A-Number (if any)2.
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
Page 7 of 7
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