Form I-821 - Application For Temporary Protected Status - U.s. Citizenship And Immigration Services

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USCIS
Application for Temporary Protected Status
Form I-821
Department of Homeland Security
OMB No. 1615-0043
U.S. Citizenship and Immigration Services
Expires 02/28/2017
For USCIS Use Only
Receipt
Action Block
Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:
Remarks
Received:
Sent:
►
START HERE - Type or print in black ink.
Part 1. Type of Application (check one)
U.S. Mailing Address
1.a.
This is my initial (first time) application for
2.a.
In Care Of Name
Temporary Protected Status (TPS). I was not
previously granted TPS.
Street Number
2.b.
1.b.
This is my re-registration application for TPS. I was
and Name
previously granted TPS.
2.c. Apt.
Ste.
Flr.
Are you also filing a request for employment authorization?
2.d.
City or Town
2.a.
Yes, I am requesting an Employment Authorization
Document (EAD), and I am filing Form I-765,
2.e. State
2.f.
ZIP Code
Application for Employment Authorization, together
with my Form I-821.
2.g.
Is your current mailing address the same as your physical
2.b.
No, I am not currently requesting employment
address?
Yes
No
authorization, but I am filing Form I-765 (as required
for administrative purposes) together with my Form
If you answered "No" to Item Number 2.g., please provide
I-821.
your physical address below.
U.S. Physical Address
Part 2. Information About You
Street Number
3.a.
1.a. Family Name
and Name
(Last Name)
3.b. Apt.
Ste.
Flr.
1.b. Given Name
(First Name)
3.c.
City or Town
1.c. Middle Name
3.d. State
3.e. ZIP Code
For USCIS Use Only
Form I-821 12/23/16 Y
Page 1 of 11

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