Form I-821D Application for Deferred Action for Childhood Arrivals

Consideration of Deferred Action
for Childhood Arrivals

USCIS
Form I-821D

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0124
Expires 06/30/2016

Receipt

A-

Action Block

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Returned:
Resubmitted:

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Relocated

For
USCIS Case ID:
Use
Requestor interviewed
Only
on
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Received:
Sent:

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/ Remarks
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To Be Completed by an Attorney or
Accredited Representative, if any.

Select this box if Form G-28 is attached to
represent the requestor.

Attorney State Bar Number (if any):

► START HERE - Type or print in black ink. Read Form I-821D Instructions for information on how to complete this form.

Part 1. Information About You (For Initial and
Renewal Requests)

Removal Proceedings Information
5.

I am not in immigration detention and I have included Form
I-765, Application for Employment Authorization, and Form
I-765WS, Form I-765 Worksheet; and

Are you NOW or have you EVER been in removal
proceedings, or do you have a removal order issued in any
other context (for example, at the border or within the
United States by an immigration agent)?
Yes

I am requesting:
Initial Request - Consideration of Deferred Action
for Childhood Arrivals

1.

NOTE: The term “removal proceedings” includes
exclusion or deportation proceedings initiated before
April 1, 1997; an Immigration and Nationality Act (INA)
section 240 removal proceeding; expedited removal;
reinstatement of a final order of exclusion, deportation, or
removal; an INA section 217 removal after admission
under the Visa Waiver Program; or removal as a criminal
alien under INA section 238.

OR
2.

Renewal Request - Consideration of Deferred
Action for Childhood Arrivals

AND
For this Renewal request, my most recent period of Deferred
Action for Childhood Arrivals expires on
(mm/dd/yyyy) ►

Full Legal Name

No

If you answered "Yes" to Item Number 5., you must select a
box below indicating your current status or outcome of your
removal proceedings.
Status or outcome:

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

5.a.

Currently in Proceedings (Active)

5.b.

Currently in Proceedings (Administratively Closed)

5.c.

Terminated

3.c. Middle Name

5.d.

Subject to a Final Order

5.e.

Other. Explain in Part 8. Additional Information.

U.S. Mailing Address (Enter the same address on
Form I-765)
4.a. In Care Of Name (if applicable)

5.f.

Most Recent Date of Proceedings
(mm/dd/yyyy) ►

5.g. Location of Proceedings
4.b. Street Number
and Name
4.c. Apt.

Ste.

Flr.

4.d. City or Town
4.e. State

4.f. ZIP Code

Form I-821D 06/04/14 N

Page 1 of 7

Part 1. Information About You (For Initial and
Renewal Requests) (continued)

Processing Information
15.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

16.

Race (Select all applicable boxes)

Other Information
6.

Alien Registration Number (A-Number) (if any)
► A-

7.

White
Asian
Black or African American

U.S. Social Security Number (if any)
►

8.

Date of Birth

9.

Gender

(mm/dd/yyyy) ►
Male

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Female

10.a. City/Town/Village of Birth

10.b. Country of Birth

11.

Current Country of Residence

12.

Country of Citizenship or Nationality

13.

Marital Status
Married

Widowed

Single

18.

Weight

19.

Eye Color (Select only one box)

Divorced

If you need additional space, use Part 8. Additional
Information.

14.c. Middle Name

Height

20.

Other Names Used (If Applicable)

14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)

17.

Feet

Inches
Pounds

Black

Blue

Brown

Gray
Maroon

Green
Pink

Hazel
Unknown/Other

Hair Color (Select only one box)
Bald (No hair)

Black

Blond

Brown
Sandy

Gray
White

Red
Unknown/
Other

Part 2. Residence and Travel Information (For
Initial and Renewal Requests)
1.

I have been continuously residing in the U.S. since at least
June 15, 2007, up to the present time.
Yes
No

NOTE: If you departed the United States for some period of
time before your 16th birthday and returned to the United States
on or after your 16th birthday to begin your current period of
continuous residence, and if this is an initial request, submit
evidence that you established residence in the United States prior
to16 years of age as set forth in the instructions to this form.
For Initial Requests: List your current address and, to the best
of your knowledge, the addresses where you resided since the
date of your initial entry into the United States to present.
For Renewal Requests: List only the addresses where you
resided since you submitted your last Form I-821D that was
approved.
If you require additional space, use Part 8. Additional
Information.

Form I-821D 06/04/14 N

Page 2 of 7

Part 2. Residence and Travel Information (For
Initial and Renewal Requests) (continued)
Present Address

Travel Information
For Initial Requests: List all of your absences from the United
States since June 15, 2007.

2.a. Dates at this residence (mm/dd/yyyy)
From ►
To ► Present

For Renewal Requests: List only your absences from the
United States since you submitted your last Form I-821D that
was approved.

2.b. Street Number
and Name

If you require additional space, use Part 8. Additional
Information.

2.c. Apt.

Ste.

Flr.

2.d. City or Town
2.e. State

2.f. ZIP Code

6.a. Departure Date

(mm/dd/yyyy) ►

6.b. Return Date

(mm/dd/yyyy) ►

6.c. Reason for Departure

Address 1
3.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►
3.b. Street Number
and Name
3.c. Apt.

Departure 1

Ste.

Flr.

Departure 2
7.a. Departure Date

(mm/dd/yyyy) ►

7.b. Return Date

(mm/dd/yyyy) ►

7.c. Reason for Departure

3.d. City or Town
3.f. ZIP Code

3.e. State

8
Address 2

Have you left the United States without advance parole on
or after August 15, 2012?
Yes
No

4.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►

9.a. What country issued your last passport?

4.b. Street Number
and Name

9.b. Passport Number

4.c. Apt.

Ste.

Flr.
9.c. Passport Expiration Date

4.d. City or Town

(mm/dd/yyyy) ►
4.f. ZIP Code

4.e. State

10.

Border Crossing Card Number (if any)

Address 3
5.a. Dates at this residence (mm/dd/yyyy)
From ►
To ►
5.b. Street Number
and Name
5.c. Apt.

Ste.

Flr.

Part 3. For Initial Requests Only
1.

I initially arrived and established residence in the U.S.
prior to 16 years of age.
Yes
No

2.

Date of Initial Entry into the United States (on or about)
(mm/dd/yyyy) ►

3.

Place of Initial Entry into the United States

5.d. City or Town
5.e. State

5.f. ZIP Code

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Part 3. For Initial Requests Only (continued)
4.

Immigration Status on June 15, 2012 (e.g., No Lawful
Status, Status Expired, Parole Expired)

5.a. Were you EVER issued an Arrival-Departure Record
(Form I-94, I-94W, or I-95)?
Yes
No

Part 4. Criminal, National Security, and Public
Safety Information (For Initial and Renewal
Requests)
If any of the following questions apply to you, use Part 8.
Additional Information to describe the circumstances and
include a full explanation.
1.

5.b. If you answered "Yes" to Item Number 5.a., provide
your Form I-94, I-94W, or I-95 number (if available).
►
5.c. If you answered "Yes" to Item Number 5.a., provide the
date your authorized stay expired, as shown on Form I-94,
I-94W, or I-95 (if available).

If you answered “Yes,” you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest, unless
disclosure is prohibited under state law.

(mm/dd/yyyy) ►

Education Information
6.

7.

2.

Indicate how you meet the education guideline (e.g.,
Graduated from high school, Received a general
educational development (GED) certificate or equivalent
state-authorized exam, Currently in school)

Name, City, and State of School Currently Attending or
Where Education Received

Have you EVER been arrested for, charged with, or
convicted of a felony or misdemeanor, including incidents
handled in juvenile court, in the United States? Do not
include minor traffic violations unless they were alcoholor drug-related.
Yes
No

Have you EVER been arrested for, charged with, or
convicted of a crime in any country other than the United
States?
Yes
No
If you answered "Yes," you must include a certified
court disposition, arrest record, charging document,
sentencing record, etc., for each arrest.

3.

Have you EVER engaged in, do you continue to engage
in, or plan to engage in terrorist activities?
Yes

8.

Date of Graduation (e.g., Receipt of a Certificate of
Completion, GED certificate, other equivalent stateauthorized exam) or, if currently in school, date of last
attendance. (mm/dd/yyyy) ►

Military Service Information
9.

Were you a member of the U.S. Armed Forces or U.S.
Coast Guard?
Yes
No

If you answered "Yes" to Item Number 9., you must provide
responses to Item Numbers 9.a. - 9.d.

No

4.

Are you NOW or have you EVER been a member of a
gang?
Yes
No

5.

Have you EVER engaged in, ordered, incited, assisted, or
otherwise participated in any of the following:

5.a. Acts involving torture, genocide, or human trafficking?
Yes
No
5.b. Killing any person?

Yes

No

5.c. Severely injuring any person?

Yes

No

9.a. Military Branch

5.d. Any kind of sexual contact or relations with any person
who was being forced or threatened?
Yes
No

9.b. Service Start Date (mm/dd/yyyy) ►

6.

Have you EVER recruited, enlisted, conscripted, or used
any person to serve in or help an armed force or group
while such person was under age 15?
Yes
No

7.

Have you EVER used any person under age 15 to take
part in hostilities, or to help or provide services to people
in combat?
Yes
No

9.c. Discharge Date

(mm/dd/yyyy) ►

9.d. Type of Discharge

Form I-821D 06/04/14 N

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Part 5. Statement, Certification, Signature, and
Contact Information of the Requestor (For Initial
and Renewal Requests)
NOTE: Select the box for either Item Number 1.a. or 1.b.
1.a.

1.b.

Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests)
Interpreter's Full Name

I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to each question.

1.a. Interpreter's Family Name (Last Name)

The interpreter named in Part 6. has read to me each
and every question and instruction on this form, as
well as my answer to each question, in

1.b. Interpreter's Given Name (First Name)

,
a language in which I am fluent. I understand each
and every question and instruction on this form as
translated to me by my interpreter, and have provided
true and correct responses in the language indicated
above.

Requestor's Certification
I certify, under penalty of perjury under the laws of the United
States of America, that the foregoing is true and correct and that
copies of documents submitted are exact photocopies of
unaltered original documents. I understand that I may be
required to submit original documents to U.S. Citizenship and
Immigration Services (USCIS) at a later date. I also understand
that knowingly and willfully providing materially false
information on this form is a federal felony punishable by a
fine, imprisonment up to 5 years, or both, under 18 U.S.C.
section 1001. Furthermore, I authorize the release of any
information from my records that USCIS may need to reach a
determination on my deferred action request.
2.a. Requestor's Signature

2.b. Date of Signature (mm/dd/yyyy) ►

Requestor's Contact Information
3.

Requestor's Daytime Telephone Number

4.

Requestor's Mobile Telephone Number

5.

Requestor's Email Address

Form I-821D 06/04/14 N

Provide the following information concerning the interpreter:

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address

Page 5 of 7

Part 6. Contact Information, Certification, and
Signature of the Interpreter (For Initial and
Renewal Requests) (continued)
Interpreter's Certification

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

I certify that:

3.c. City or Town

I am fluent in English and
which
is the same language provided in Part 5., Item Number 1.b.;

3.d. State

I have read to this requestor each and every question and
instruction on this form, as well as the answer to each question,
in the language provided in Part 5., Item Number 1.b.; and

3.f.

The requestor has informed me that he or she understands each
and every instruction and question on the form, as well as the
answer to each question.

3.h. Country

6.a. Interpreter's Signature

Flr.

3.e. ZIP Code

Province

3.g. Postal Code

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

Preparer's Email Address

6.b. Date of Signature (mm/dd/yyyy) ►

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
If Other than the Requestor (For Initial and
Renewal Requests)
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

Preparer's Declaration
I declare that I prepared this Form I-821D at the requestor's
behest, and it is based on all the information of which I have
knowledge.
7.a. Preparer's Signature

1.b. Preparer's Given Name (First Name)
7.b. Date of Signature (mm/dd/yyyy) ►
2.

Preparer's Business or Organization Name
NOTE: If you need extra space to complete any item within
this request, see the next page for Part 8. Additional
Information.

Form I-821D 06/04/14 N

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Part 8. Additional Information (For Initial and
Renewal Requests)
If you need extra space to complete any item within this
request, use the space below. You may also make copies of this
page to complete and file with this request. Include your name
and A-Number (if any) at the top of each sheet of paper;
indicate the Page Number, Part Number, and Item Number
to which your answer refers; and sign and date each sheet.

4.a. Page Number

4.b. Part Number

4.c. Item Number

5.b. Part Number

5.c. Item Number

4.d.

Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

A-Number (if any)
► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.
5.a. Page Number

5.d.

Form I-821D 06/04/14 N

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