Form I-821 - Application For Temporary Protected Status Page 11
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13Part 8. Applicant's Statement, Contact
Part 9. Interpreter's Contact Information,
Information, Certification, and Signature
Certification, and Signature
(continued)
Provide the following information about the interpreter.
Applicant's Contact Information
Interpreter's Full Name
3.
Applicant's Daytime Telephone Number
1.a. Interpreter's Family Name (Last Name)
4.
Applicant's Mobile Telephone Number (if any)
1.b. Interpreter's Given Name (First Name)
5.
Applicant's Email Address (if any)
2.
Interpreter's Business or Organization Name (if any)
Applicant's Certification
Interpreter's Mailing Address
Copies of any documents I have submitted are exact photocopies
3.a. Street Number
of unaltered, original documents, and I understand that USCIS
and Name
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
3.b.
Apt.
Ste.
Flr.
from any of my records that USCIS may need to determine my
eligibility for the immigration benefit I seek.
3.c. City or Town
I further authorize release of information contained in this
3.d. State
3.e. ZIP Code
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
3.f.
Province
administration and enforcement of U.S. immigration laws.
I understand that USCIS may require me to appear for an
3.g. Postal Code
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
3.h. Country
oath reaffirming that:
1) I reviewed and provided or authorized all of the
information in my application;
Interpreter's Contact Information
2) I understood all of the information contained in, and
4.
Interpreter's Daytime Telephone Number
submitted with, my application; and
3) All of this information was complete, true, and correct
5.
Interpreter's Mobile Telephone Number (if any)
at the time of filing.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
6.
Interpreter's Email Address (if any)
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.
Applicant's Signature
Interpreter's Certification
6.a. Applicant's Signature
I certify, under penalty of perjury, that:
I am fluent in English and
,
6.b. Date of Signature (mm/dd/yyyy)
which is the same language specified in Part 8., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
NOTE TO ALL APPLICANTS: If you do not completely fill
answer to every question. The applicant informed me that he or
out this application or fail to submit required documents listed
she understands every instruction, question and answer on the
in the Instructions, USCIS may deny your application.
application, including the Applicant's Certification, and has
verified the accuracy of every answer.
Form I-821 10/19/17 N
Page 11 of 13
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