Form I-821 - Application For Temporary Protected Status - U.s. Citizenship And Immigration Services Page 7
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117.a. Have you EVER or are you NOW engaged in terrorist
Part 4. Eligibility Standards (continued)
activities?
Yes
No
5.b.
Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
7.b.
Have you EVER or are you NOW engaged in or plan to
Yes
No
engage in activities in the United States that would have
5.c.
Are you NOW or have you EVER knowingly assisted,
potentially serious adverse foreign policy consequences
abetted, conspired, or colluded with others in the unlawful
for the United States?
Yes
No
trafficking of any controlled substance?
7.c.
Have you EVER been or are you NOW a member of the
Yes
No
Communist or other totalitarian party, except when
5.d. Are you the spouse or child of an alien who unlawfully
membership was involuntary?
Yes
No
trafficked in any controlled substance?
Have you EVER participated in Nazi persecution or
7.d.
Yes
No
genocide?
Yes
No
5.e.
Are you the spouse or child of an alien who assisted,
abetted, conspired, or colluded with others in the unlawful
Have you EVER been arrested, cited, charged, indicted,
8.a.
trafficking of any controlled substance?
fined, or imprisoned for breaking or violating any law or
ordinance, excluding minor traffic violations?
Yes
No
Yes
No
5.f.
Within the previous 5 years, have you EVER obtained
any financial or other benefit from the unlawful activity
Have you EVER been the beneficiary of a pardon,
8.b.
of your spouse (including former spouses) or parents, and
amnesty, rehabilitation decree, other act of clemency, or
you knew, or reasonably should have known, that the
similar action?
Yes
No
financial or other benefit was the product of such illicit
activity?
9.
Have you EVER committed a serious criminal offense in
Yes
No
the United States and asserted immunity from
prosecution?
Yes
No
Have you EVER engaged, or do you plan to engage, solely,
principally, or incidentally, in any of the following:
10.a. Have you EVER, within the past 10 years, or are you
6.a.
Any activity to violate any law of the United States
NOW engaged in prostitution or procurement of
relating to espionage or sabotage?
prostitution?
Yes
No
Yes
No
6.b.
Any activity to violate or evade any law prohibiting the
10.b.
Have you EVER, within the past 10 years (either directly
export from the United States of goods, technology, or
or indirectly) procured or attempted to procure or import,
sensitive information?
prostitutes or persons for the purpose of prostitution?
Yes
No
Yes
No
6.c.
Any other unlawful activity in the United States?
10.c.
Have you EVER, within the past 10 years, received, in
Yes
No
whole or in part, the proceeds of prostitution?
6.d.
Any activity in which a purpose is the opposition to, or the
Yes
No
control or overthrow of, the Government of the United
States by force, violence, or other unlawful means,
11.
Have you EVER been or do you intend to be involved in
including but not limited to, participating in such activities,
any other commercial vice?
Yes
No
giving support to others involved in such activities, or being
a member or representative of a terrorist organization?
12.a.
Have you EVER been ordered removed, and been
deported from the United States?
Yes
No
Yes
No
For USCIS Use Only
Form I-821 12/23/16 Y
Page 7 of 11
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