Form I-821 Temporary Protected Status (TPS)

Form I-821 Temporary Protected Status (TPS)
Type of Application
Who granted TPS?
Work Permit Option (filing I-765 together)
TPS Country - Name of designated country
Applicant’s Personal Information
Last Name
First Name
Middle Name
Other Name Used 1
Other Name Used 2
In Care Of
Mailing Street Address
Mailing Apartment / Suite
Mailing City
Mailing State
Mailing ZIP Code
Same as Physical Address?
Physical Street Address
Physical Apartment / Suite
Physical City
Physical State
Physical ZIP Code
A-Number
USCIS Online Account Number
Social Security Number
Date of Birth

MonthDayYear
Date
Other Date of Birth Used
Immigration and Travel Details
Date of last entry to U.S.

MonthDayYear
Date
Status at entry
Port of entry
I-94 Number
I-94 Expiration

MonthDayYear
Date
Passport Number(s)
Travel Document Number
Country of issuance (passport/travel document)
Passport/Travel Document Expiration date

MonthDayYear
Date
Current immigration status
Ever in immigration proceedings?
Type of proceedings (court / BIA / federal)
Proceedings location and dates
Biometrics
Ethnicity
Race
Height
Weight
Eye Color
Hair Color
Spouse and Former Spouse Information
Current Spouse Name

First NameMiddle NameLast Name
Current Spouse A-Number
Current Spouse Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current Spouse Date of Birth

MonthDayYear
Date
Current Spouse Marriage Date

MonthDayYear
Date
Place of Marriage
Current Spouse TPS History
Former Spouse 1 Name

First NameMiddle NameLast Name
Former Spouse 1 Nationality
Former Spouse 1 A-Number
Former Spouse 1 Date of Birth

MonthDayYear
Date
Former Spouse 1 Marriage Date

MonthDayYear
Date
Former Spouse 1 Divorce or Death Information and TPS History
Former Spouse 2 Name

First NameMiddle NameLast Name
Children’s Information
Child 1 Full Name

First NameMiddle NameLast Name
Child 1 A-Number
Child 1 Date of Birth

MonthDayYear
Date
Child 1 Address
Child 1 TPS Dates
Child 1 Applying for TPS?
Child 2 Full Name

First NameMiddle NameLast Name
Child 2 A-Number
Child 2 Date of Birth

MonthDayYear
Date
Child 2 Address
Child 2 TPS Dates
Child 2 Applying for TPS?
TPS Eligibility and Immigration History
Country of nationality
Initial entry date for TPS eligibility

MonthDayYear
Date
Travel history
Other immigration offers / relief
Criminal, Security, and Immigration Violations
Have you ever been convicted of a felony?
Have you ever been convicted of a misdemeanor?
Have you ever violated any drug-related laws?
Have you ever engaged in prostitution or received proceeds from prostitution?
Arrests and charges
Have you ever been involved in terrorism-related activities?
Have you ever been involved in espionage?
Have you ever served in any military unit or armed group?
Have you ever used or possessed weapons unlawfully?
Organizations, groups, or associations
Have you ever been deported, removed, or excluded from the United States?
Other Admissibility Questions
Health conditions or public safety concerns, including child custody issues
Have you ever engaged in polygamy?
Declaration and Signature
Applicant Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Form I-821 Temporary Protected Status (TPS)

Applicant’s Personal Information

Immigration and Travel Details

Biometrics

Spouse and Former Spouse Information

Children’s Information

TPS Eligibility and Immigration History

Criminal, Security, and Immigration Violations

Other Admissibility Questions

Declaration and Signature