Form I-821 - Application For Temporary Protected Status

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USCIS
Application for Temporary Protected Status
Form I-821
Department of Homeland Security
OMB No. 1615-0043
Expires 03/31/2019
U.S. Citizenship and Immigration Services
For USCIS Use Only
Receipt
Action Block
Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:
Remarks
Received:
Sent:
To be completed
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
by an Attorney
Form G-28 or
(if applicable)
USCIS Online Account Number (if any)
or Accredited
G-28I is
Representative (if any).
attached.
► START HERE - Type or print in black ink.
Part 1. Type of Application (select one)
Are you also filing a request for employment authorization?
NOTE: Select the box for Item Number 1.a., 1.b., or 2. If
3.a.
Yes, I am requesting an Employment Authorization
applicable, select the box for Item Number 3.a. or 3.b. For
Document (EAD), and I am filing Form I-765,
Item Number 4., enter the name of the designated TPS country.
Application for Employment Authorization, together
with my Form I-821.
1.a.
This is my initial (first time) application for
3.b.
No, I am not currently requesting an EAD.
Temporary Protected Status (TPS). I do not currently
have TPS.
Name of designated TPS country under which you are
4.
applying.
1.b.
This is my re-registration application for TPS. I
currently have TPS, and am applying to re-register.
NOTE: If you have previously applied or have a
pending application for TPS, but do not currently
Part 2. Information About You
have TPS, select Item Number 1.a. and describe
each time that you previously applied, including the
Your Full Name
receipt number (if available) and the outcome (if any)
1.a. Family Name
of each application. If you currently have a pending
(Last Name)
TPS application, please also describe when you filed
1.b. Given Name
it and the application receipt number (if available) in
(First Name)
Part 11. Additional Information. If you do not
recall or have incomplete information on your prior
1.c. Middle Name
TPS applications, please provide the information you
can, even if incomplete.
2.
If you selected Item Number 1.b., please indicate who
granted you TPS.
USCIS
Immigration Judge/Board of Immigration Appeals
Form I-821 10/19/17 N
Page 1 of 13

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