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
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