Form I-821 - Application For Temporary Protected Status Page 2
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13Part 2. Information About You (continued)
Other Information
7.
Alien Registration Number (A-Number) (if any)
Other Names Used
►
A-
Provide all other names you have used since birth, including
8.
USCIS Online Account Number (if any)
aliases, maiden name, and nicknames. If you need extra space
►
to complete this section, use the space provided in Part 11.
Additional Information.
9.
U.S. Social Security Number (if any)
2.a. Family Name
►
(Last Name)
2.b. Given Name
10.
Date of Birth (mm/dd/yyyy)
(First Name)
2.c. Middle Name
Other Dates of Birth Used (if any)
3.a. Family Name
Provide all other dates of birth you have ever used. If you need
(Last Name)
extra space to complete this section, use the space provided in
3.b. Given Name
Part 11. Additional Information.
(First Name)
11.a. Other Date of Birth
3.c. Middle Name
(mm/dd/yyyy)
11.b. Other Date of Birth
U.S. Mailing Address
(mm/dd/yyyy)
4.a. In Care Of Name
12.
Gender
Male
Female
13.
City/Town/Village of Birth
4.b. Street Number
and Name
14.
Country of Birth
4.c.
Apt.
Ste.
Flr.
4.d. City or Town
Countries of Residence (Before entering the U.S.)
4.e. State
4.f.
ZIP Code
15.a.
15.b.
5.
Is your current mailing address the same as your physical
address (where you live)?
Yes
No
15.c.
15.d.
If you answered "No" to Item Number 5., please provide your
physical address below.
Country or Countries of Citizenship or Nationality (if any)
(List all countries that apply.)
U.S. Physical Address
16.a.
6.a. Street Number
and Name
16.b.
6.b.
Apt.
Ste.
Flr.
16.c.
16.d.
6.c. City or Town
Your Marital Information
6.d. State
6.e. ZIP Code
17.
Current Marital Status (Select only one box)
Married
Single, Never Married
Divorced
Widowed
Separated
Marriage Annulled
Other
Form I-821 10/19/17 N
Page 2 of 13
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