Form I-821 - Application For Temporary Protected Status Page 9
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1323.a. Do you NOW have a communicable disease of public
Part 7. Eligibility Standards (continued)
health significance?
Yes
No
16.
Have you EVER been the beneficiary of a pardon,
amnesty, rehabilitation decree, other act of clemency, or
23.b. Do you NOW have or have you EVER had a physical or
similar action?
mental disorder and behavior (or a history of behavior that
Yes
No
is likely to recur) associated with the disorder which has
17.
Have you EVER committed a serious criminal offense in
posed or may pose a threat to the property, safety, or
the United States and asserted immunity from
welfare of yourself or others?
Yes
No
prosecution?
Yes
No
23.c. Are you NOW or have you EVER been a drug abuser or
18.a. Have you EVER, within the past 10 years, or are you
drug addict?
Yes
No
NOW engaged in prostitution or procurement of
prostitution?
24.
Have you EVER entered the United States as a
Yes
No
stowaway?
Yes
No
18.b.
Have you EVER, within the past 10 years (either directly
or indirectly) procured or attempted to procure or import
25.
Did the former Immigration and Naturalization Service
prostitutes or persons for the purpose of prostitution?
(INS) EVER impose, or has DHS EVER imposed, civil
monetary penalties on you for producing or using false
Yes
No
documentation to obtain an immigration benefit?
18.c. Have you EVER, within the past 10 years, received, in
Yes
No
whole or in part, the proceeds of prostitution?
26.
Are you NOW subject to a final order for violation of
Yes
No
section 274C (producing and/or using false
19.
Have you EVER been or do you intend to be involved in
documentation to unlawfully satisfy a requirement of the
any other commercial vice?
Immigration and Nationality Act)?
Yes
No
Yes
No
20.a. Have you EVER been ordered removed, and been
27.
Do you NOW practice polygamy?
Yes
No
deported from the United States?
Yes
No
28.
Are you NOW the guardian of, and are you
20.b. Have you EVER voluntarily departed the United States
accompanying, another individual who has been found to
under an order of removal?
be inadmissible and who has been certified by a medical
Yes
No
examiner to be helpless due to sickness, physical or
20.c. If you answered "Yes" to either Item Number 20.a. or
mental disability, or infancy?
Yes
No
20.b. above, have you re-entered the United States
unlawfully at any time after you were deported or you
29.
Have you EVER detained, retained, or withheld the
voluntarily departed?
custody of a child having a lawful claim to U.S.
Yes
No
citizenship, outside the United States, from a U.S. citizen
20.d. If you answered "Yes" to Item Number 20.c. above, has
granted custody?
Yes
No
DHS reinstated your prior order of removal?
Have you EVER ordered, incited, called for, committed,
Yes
No
I Do Not Know
assisted, helped with, or otherwise participated in any of the
20.e. Have you EVER failed to attend or remain in attendance
following:
at any immigration proceedings to determine your
30.a. Acts involving torture or genocide?
Yes
No
admissibility or deportability?
Yes
No
30.b. Killing any person?
Yes
No
21.
Have you EVER, by fraud or willfully misrepresenting a
material fact, sought to obtain a visa or other
30.c. Intentionally and severely injuring any person?
documentation, admission to the United States, or any
Yes
No
other immigration benefit?
Yes
No
30.d. Engaging in any kind of sexual contact or relations with
22.
Have you EVER assisted any other person to enter the
any person who was being forced or threatened?
United States in violation of the law?
Yes
No
Yes
No
30.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
Form I-821 10/19/17 N
Page 9 of 13
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