Immigration Services All Other
Resume:
Electronic
Form
Only
Form I-*** **/**/** Electronic Form Only Page 1 of 13
To be completed
by an Attorney
or Accredited
Representative (if any).
For USCIS Use Only
Receipt Action Block
START HERE - Type or print in black ink.
Application for Temporary Protected Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
Remarks
Case ID:
A-Number:
Returned:
Resubmitted:
Relocated:
Sent:
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Part 1. Type of Application (select one)
NOTE: Select the box for Item Number 1.a., 1.b., or 2. If applicable, select the box for Item Number 3.a. or 3.b. For Item Number 4., enter the name of the designated TPS country. This is my initial (first time) application for
Temporary Protected Status (TPS). I do not currently have TPS.
1.a.
This is my re-registration application for TPS. I
currently have TPS, and am applying to re-register. 1.b.
NOTE: If you have previously applied or have a
pending application for TPS, but do not currently
have TPS, select Item Number 1.a. and describe
each time that you previously applied, including the receipt number (if available) and the outcome (if any) of each application. If you currently have a pending TPS application, please also describe when you filed it and the application receipt number (if available) in Part 11. Additional Information. If you do not
recall or have incomplete information on your prior TPS applications, please provide the information you can, even if incomplete.
If you selected Item Number 1.b., please indicate who granted you TPS.
2.
USCIS
Immigration Judge/Board of Immigration Appeals
Are you also filing a request for employment authorization? Yes, I am requesting an Employment Authorization
Document (EAD), and I am filing Form I-765,
Application for Employment Authorization, together with my Form I-821.
3.a.
3.b. No, I am not currently requesting an EAD.
Name of designated TPS country under which you are applying.
4.
Haiti
Part 2. Information About You
Your Full Name
1.c. Middle Name
Given Name GUINEL
(First Name)
1.b.
Family Name CHERISSAINT
(Last Name)
1.a.
Select this box
if Form G-28 or
G-28I is
attached.
Received:
USCIS
Form I-821
OMB No. 1615-0043
Expires 02/28/2027
Electronic
Form
Only
Form I-821 04/01/24 Electronic Form Only Page 2 of 13 Provide all other names you have used since birth, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
Other Names Used
Part 2. Information About You (continued)
2.c. Middle Name
Given Name
(First Name)
2.b.
Family Name
(Last Name)
2.a.
3.c. Middle Name
Given Name
(First Name)
3.b.
Family Name
(Last Name)
3.a.
U.S. Mailing Address
If you answered "No" to Item Number 5., please provide your physical address below.
Is your current mailing address the same as your physical address (where you live)?
5.
4.e. State IL 4.f. Zip Code 62650
4.d. City or Town JACKSONVILLE
4.c. Apt. Ste. Flr.
Street Number 8 GREENBRIAR DR APT 2B
and Name
4.b.
4.a. In Care of Name (if any)
Yes No
U.S. Physical Address
State 6.e. Zip Code
City or Town
6.d.
Apt. Ste. Flr.
6.c.
Street Number
and Name
6.b.
6.a.
8. USCIS Online Account Number (if any)
7. Alien Registration Number (A-Number) (if any)
Other Information
A- 233731939
***-**-****
9. U.S. Social Security Number (if any)
10. Date of Birth (mm/dd/yyyy) 01/27/2005
Other Dates of Birth Used (if any)
Provide all other dates of birth you have ever used. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
Other Date of Birth
(mm/dd/yyyy)
11.a.
Other Date of Birth
(mm/dd/yyyy)
11.b.
12. Gender Male Female
Haiti
14. Country of Birth
CAP-HAITIEN
13 City/Town/Village of Birth
Countries of Residence (Before entering the U.S.)
15.a. Haiti
15.b.
15.c.
15.d.
16.d.
16.c.
16.b.
16.a. Haiti
Country or Countries of Citizenship or Nationality (if any)
(List all countries that apply.)
Divorced Widowed
Single, Never Married Married
17. Current Marital Status (Select only one box)
Your Marital Information
Separated Marriage Annulled
Other
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Date of Current Marriage (if currently married)
(mm/dd/yyyy)
18.
U.S. Entry Information
Date of Last Entry into the United States
(mm/dd/yyyy)
02/02/2024
19.
Immigration Status (or Lack of Status) When You Last Entered the United States (for example, visitor, student, no status)
20.
21.
Place of Last Entry into the United States
HHP - Haiti Humanitarian Parole
U.S. Port of Entry (if any)
22.a. City or Town
22.b. State
751436777A3
23. Form I-94 Arrival-Departure Record Number (if any) Date Your Authorized Period of Stay in the United States Expired or Will Expire (as shown on Form I-94 or
Crewman's Landing Permit (Form I-95)) (mm/dd/yyyy or duration of status (D/S)
24.
01/31/2026
Passport Number (most recent passport) (if any) (If you have other expired or valid passports, please list all of them and provide all information requested below about each passport.)
25.
26. Travel Document Number (if any)
27. Additional Passport or Travel Document Number
28. Additional Passport or Travel Document Number
Haiti
Country of Issuance for most recent Passport or Travel Document
29.
30. Expiration Date for most recent Passport or Travel Document (mm/dd/yyyy)
HHP - Haiti Humanitarian Parole
31. Current Immigration Status or Lack of Status
Your Current Immigration Status
Are you now or were you EVER in immigration
proceedings?
32.
Yes No
If you answered "Yes" to Item Number 32., provide the following information.
Type of Proceedings (Select all boxes that apply): 33.a.
33.b.
33.c.
Immigration Court (before an Immigration Judge)
Board of Immigration Appeals (BIA)
I am no longer in Department of Justice (DOJ) or
Department of Homeland Security (DHS)
immigration proceedings, but I am or was in Federal court proceedings regarding immigration issues.
Locations Where Your DOJ and/or DHS Proceedings were Held (or are currently being held) (if applicable) 34.
Locations Where Your Federal Court Proceedings
Regarding Immigration Issues were Held (or are currently being held) (if applicable)
35.
Dates for Your Proceedings
NOTE: If your proceedings are ongoing, leave the “To” date blank. If you have been in more than one type of proceedings, or in Federal Court, list dates for each time period. 36.a. From (mm/dd/yyyy)
36.b. To (mm/dd/yyyy)
36.c. Present
Part 3. Biographic Information
Not Hispanic or Latino
Hispanic or Latino
1. Ethnicity (Select only one box)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Black or African American
Asian
White
2. Race (Select all applicable boxes)
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Inches 7
Pounds 138
Feet 5
4. Weight
3. Height
Unknown/Other
Sandy White
Brown Gray Red
Bald (No hair) Black Blond
6. Hair Color (Select only one box)
Unknown/Other
Hazel
Brown
Pink
Green
Blue
Maroon
Gray
Black
5. Eye Color (Select only one box)
Part 4. Information About Your Current Spouse
(if any)
Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses and all of your children, please use the space provided in Part 11. Additional Information.
Provide the following information about your current spouse (if married).
A-
2. A-Number (if any and if known)
1. USCIS Online Account Number (if any and if known)
3.c. Middle Name
Given Name
(First Name)
3.b.
Family Name
(Last Name)
3.a.
4.d. State 4.e. Zip Code
4.c. City or Town
4.b. Apt. Ste. Flr.
Street Number
and Name
4.a.
4.f.
Mailing Address of Spouse
Province
4.g. Postal Code
4.h. Country
6. Date of Marriage to Your Current Spouse
(mm/dd/yyyy)
Your Spouse's Date of Birth
(mm/dd/yyyy)
5.
Other Information About Your Current Spouse
7. Place of Marriage to Your Current Spouse
8.a. City or Town
8.b. State
8.c. Province (if any)
8.d. Country
Yes No
9. If you know, has your current spouse EVER had TPS? If yes, what dates did he or she have TPS?
10.c. Present
10.b. To (mm/dd/yyyy)
10.a. From (mm/dd/yyyy)
10.d. I do not know the dates
Yes No
11. Is your spouse's TPS still valid? (if known)
I Do Not Know
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Form I-821 04/01/24 Electronic Form Only Page 5 of 13 Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses or all of your children, please use the space provided in Part 11. Additional Information.
Part 5. Information About Your Former Spouses
(if any)
Names of All Your Former Spouses (if any)
1.c. Middle Name
Given Name
(First Name)
1.b.
Family Name
(Last Name)
1.a.
First Marriage
2. Nationalities of Former Spouse
A-
3. A-Number of Former Spouse (if any and if known) Date of Birth of Former Spouse
(mm/dd/yyyy)
4.
Date of Death if Former Spouse Deceased
(mm/dd/yyyy)
5.
Dates of Marriage to Former Spouse
6.b. To (mm/dd/yyyy)
6.a. From (mm/dd/yyyy)
How Marriage Ended (for example, divorce, widowed, annulled)
7.
Yes No I Do Not Know
Is this former spouse currently applying for or re- registering for TPS (if known)?
10.
9.d. I do not know the dates
9.c. Present
9.b. To (mm/dd/yyyy)
9.a. From (mm/dd/yyyy)
If yes, what dates did he or she have TPS (if known)? 8. Did or does this former spouse have TPS (if known)? Yes No I Do Not Know
11.c. Middle Name
Given Name
(First Name)
11.b.
Family Name
(Last Name)
11.a.
Second Marriage
12. Nationalities of Former Spouse
A-
13. A-Number of Former Spouse (if any and if known) Date of Birth of Former Spouse
(mm/dd/yyyy)
14.
Date of Death if Former Spouse Deceased
(mm/dd/yyyy)
15.
Dates of Marriage to Former Spouse
16.b. To (mm/dd/yyyy)
16.a. From (mm/dd/yyyy)
How Marriage Ended (for example, divorce, widowed, annulled)
17.
Yes No I Do Not Know
Is this former spouse currently applying for or re- registering for TPS (if known)?
20.
19.d. I do not know the dates
19.c. Present
19.b. To (mm/dd/yyyy)
19.a. From (mm/dd/yyyy)
If yes, what dates did he or she have TPS (if known)? 18. Did or does this former spouse have TPS (if known)? Yes No I Do Not Know
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(if any)
Complete this section only if you are filing a late initial application for TPS. See the form instructions for information on requirements for late initial filing for TPS. If you need extra space to complete this section on all former spouses and all of your children, please use the space provided in Part 11. Additional Information.
Provide the following information about each of your children
(if any). If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 1.c. Middle Name
Given Name
(First Name)
1.b.
Family Name
(Last Name)
1.a.
Child 1
2.
A-
Alien Registration Number (A-Number) (if any and if known)
3.
4. Date of Birth (mm/dd/yyyy)
USCIS Online Account Number (if any and if known)
5.d. State 5.e. Zip Code
5.c. City or Town
5.b. Apt. Ste. Flr.
Street Number
and Name
5.a.
5.f.
Mailing Address
Province
5.g. Postal Code
5.h. Country
Yes No
If you know, is this child currently applying for or re- registering for TPS (if known)?
7.
6.b. To (mm/dd/yyyy)
6.a. From (mm/dd/yyyy)
If this child has or had TPS, please provide the dates of his or her TPS (if known).
8.c. Middle Name
Given Name
(First Name)
8.b.
Family Name
(Last Name)
8.a.
Child 2
9.
A-
Alien Registration Number (A-Number) (if any and if known)
10.
11. Date of Birth (mm/dd/yyyy)
USCIS Online Account Number (if any and if known)
12.d. State 12.e. Zip Code
12.c. City or Town
12.b. Apt. Ste. Flr.
Street Number
and Name
12.a.
12.f.
Mailing Address
Province
12.g. Postal Code
12.h. Country
Yes No
If you know, is this child currently applying for or re- registering for TPS (if known)?
14.
13.b. To (mm/dd/yyyy)
13.a. From (mm/dd/yyyy)
If this child has or had TPS, please provide the dates of his or her TPS (if known).
Part 7. Eligibility Standards
Basis for Eligibility
Provide the following information:
Haiti
I am a national of (or a person having no nationality who last habitually resided in the country of):
1.a.
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02/02/2024
I entered the United States on the following date, and have resided in the United States since that time. 1.b.
(mm/dd/yyyy)
Yes No
Have you EVER traveled to and entered another country, other than the one listed in Item Number 1.a. before you last entered the United States?
1.c.
If you answered "Yes" to Item Number 1.c., provide the information requested in Item Numbers 2. - 5. for EACH country you traveled to and entered prior to entering the United States. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. Name of All the Other Countries to Which You Traveled and Entered Prior to Entering the United States
2.
Dates That You Were in the Other Country or Countries 3.b. To (mm/dd/yyyy)
3.a. From (mm/dd/yyyy)
Your Immigration Status, if Any, in the Other Country
(for example, citizen, legal permanent resident, refugee, asylee, visitor, student, temporary resident, or no status) 4.
Have you EVER been offered any immigration status by another country that you did not accept?
5.
6. If you answered "Yes" to Item Number 5., please describe the country or countries, the nature of the immigration status you were offered, and the dates when it was offered.
If you answered “Yes” to Item Number 5., please
describe why you chose not to accept the immigration status offered to you by the other country or countries. 7.
Your Immigration and Criminal History
To be eligible for TPS, you must be admissible as an immigrant to the United States, with certain exceptions. The questions below and your responses to these questions will help USCIS determine if you are eligible for TPS. See the Who Is Eligible for TPS section of the Instructions for additional information on admissibility and available waivers.
If any of the questions apply to you, please provide information about the events, including the places and dates of occurrence. Provide a full explanation of the circumstances related to the specific event. If you need additional space to respond to a question, use the space provided in Part 11. Additional Information.
If you were EVER arrested or detained for an offense, you must provide information about the event regardless of the country where the event occurred. If you were arrested, charged, or convicted for an offense, you must provide certified court dispositions showing the court proceedings' outcome wherever possible. You also must provide copies of arrest reports, statements of charges, indictment information, or any other charging document issued against you. If you were not charged with any crime or offense, provide a statement or other documentation from the arresting authority or prosecutor's office to show that you were not charged with any crime or offense.
Criminal Offenses
NOTE: If you are not able to provide the documentation requested above, provide a signed statement as to why you cannot provide such documentation. USCIS usually needs supporting documentation, however, we do recognize that country conditions in certain TPS-designated countries may not allow an applicant to obtain the documents. Each statement will be carefully reviewed by USCIS, and we may need to ask you for additional information.
Please carefully read Item 6. in the General Requirements section of the Instructions for additional information that you must provide if official documents regarding your criminal history are not available to you.
If you have ever engaged in, ordered, incited, assisted, or otherwise participated in any human rights violations, you must provide information about the events, including the place and date, and a description of the event regardless of the country where the events occurred.
Human Rights Violations
Have you EVER been convicted of:
Yes No
8.a. Any felony committed in the United States?
Yes No
8.b. Any misdemeanor committed in the United States? Yes No
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Yes No
Any particularly serious crime committed either in or outside the United States?
8.c.
9.a. Have you EVER ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion? Yes No
Have you EVER committed serious nonpolitical crimes outside of the United States prior to your arrival in the United States?
9.b.
Yes No
Have you EVER or are you NOW engaged in activities that could be reasonable grounds for concluding that you are a danger to the security of the United States? 9.c.
Have you EVER been convicted of or have you EVER
committed acts which constitute the essential elements of: 10.a. A crime (other than a purely political offense)? A violation of any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act?
10.b.
Yes No
A conspiracy to violate any law relating to a controlled substance as defined in section 102 of the Controlled Substances Act?
10.c.
Yes No
Have you EVER been convicted of two or more criminal offenses (other than purely political offenses) for which you received sentences to confinement that, when
combined, total five years or more?
11.
Yes No
Have you EVER trafficked in or are you NOW
trafficking in any controlled substance?
12.a.
Yes No
Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance?
12.b.
Yes No
Are you the spouse or child of an alien who unlawfully trafficked in any controlled substance?
12.c.
Yes No
Are you the spouse or child of an alien who assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance?
12.d.
Yes No
Within the previous five years, have you EVER obtained any financial or other benefit from the unlawful activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have known, that the financial or other benefit was the product of such illicit activity?
12.e.
Yes No
Have you EVER engaged, or do you plan to engage, solely, principally, or incidentally, in any of the following: Any activity to violate any law of the United States relating to espionage or sabotage?
13.a.
Yes No
Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information?
13.b.
Yes No
13.c. Any other unlawful activity in the United States? Yes No
Any activity in which a purpose is to oppose, control, or overthrow the Government of the United States by force, violence, or other unlawful means, including but not limited to participating in such activities, giving support to others involved in such activities, or being a member or representative of a terrorist organization?
13.d.
Yes No
Have you EVER or are you NOW engaged in terrorist
activities?
14.a.
Yes No
Have you EVER or are you NOW engaged in or plan to engage in activities in the United States that would have potentially serious adverse foreign policy consequences for the United States?
14.b.
Yes No
Have you EVER been or are you NOW a member of the
Communist or other totalitarian party, except when membership was involuntary?
14.c.
Yes No
Have you EVER participated in Nazi persecution or
genocide?
14.d.
Yes No
Have you EVER, whether in the United States or any other country been:
Arrested, for breaking or violating any law or ordinance, excluding minor traffic violations?
15.a.
Yes No
Cited, charged, or indicted, for breaking or violating any law or ordinance, excluding minor traffic violations? 15.b.
Yes No
Been convicted, fined, imprisoned, placed on probation, received a suspended sentence or deferral of adjudication for breaking or violating any law or ordinance, excluding minor traffic violations?
15.c.
Yes No
Yes No
Yes No
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amnesty, rehabilitation decree, other act of clemency, or similar action?
16.
Part 7. Eligibility Standards (continued)
Yes No
Have you EVER committed a serious criminal offense in the United States and asserted immunity from
prosecution?
17.
Yes No
Have you EVER, within the past 10 years, or are you NOW engaged in prostitution or procurement of
prostitution?
18.a.
Yes No
18.b. Have you EVER, within the past 10 years (either directly or indirectly) procured or attempted to procure or import prostitutes or persons for the purpose of prostitution? Yes No
Have you EVER, within the past 10 years, received, in whole or in part, the proceeds of prostitution?
18.c.
Yes No
Have you EVER been or do you intend to be involved in any other commercial vice?
19.
Yes No
Have you EVER been ordered removed, and been
deported from the United States?
20.a.
Yes No
Have you EVER voluntarily departed the United States under an order of removal?
20.b.
Yes No
If you answered "Yes" to either Item Number 20.a. or 20.b. above, have you re-entered the United States unlawfully at any time after you were deported or you voluntarily departed?
20.c.
Yes No
If you answered "Yes" to Item Number 20.c. above, has DHS reinstated your prior order of removal?
20.d.
Yes No
Have you EVER failed to attend or remain in attendance at any immigration proceedings to determine your
admissibility or deportability?
20.e.
Yes No I Do Not Know
Have you EVER, by fraud or willfully misrepresenting a material fact, sought to obtain a visa or other
documentation, admission to the United States, or any other immigration benefit?
21.
Yes No
Have you EVER assisted any other person to enter the United States in violation of the law?
22.
Yes No
Do you NOW have a communicable disease of public
health significance?
23.a.
Yes No
Do you NOW have or have you EVER had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others?
23.b.
Yes No
Are you NOW or have you EVER been a drug abuser or drug addict?
23.c.
Yes No
Have you EVER entered the United States as a
stowaway?
24.
Yes No
Did the former Immigration and Naturalization Service
(INS) EVER impose, or has DHS EVER imposed, civil
monetary penalties on you for producing or using false documentation to obtain an immigration benefit?
25.
Yes No
Are you NOW subject to a final order for violation of section 274C (producing and/or using false
documentation to unlawfully satisfy a requirement of the Immigration and Nationality Act)?
26.
Yes No
27. Do you NOW practice polygamy? Yes No
Are you NOW the guardian of, and are you
accompanying, another individual who has been found to be inadmissible and who has been certified by a medical examiner to be helpless due to sickness, physical or mental disability, or infancy?
28.
Yes No
Have you EVER detained, retained, or withheld the
custody of a child having a lawful claim to U.S.
citizenship, outside the United States, from a U.S. citizen granted custody?
29.
Yes No
Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
30.a. Acts involving torture or genocide? Yes No
30.b. Killing any person? Yes No
30.c. Intentionally and severely injuring any person? Yes No
Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?
30.d.
Yes No
Limiting or denying any person's ability to exercise religious beliefs?
30.e.
Yes No
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31.a.
Part 7. Eligibility Standards (continued)
Yes No
Have you EVER:
Served or worked in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?
31.b.
Yes No
Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?
32.
Yes No
Have you EVER assisted with or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person?
33.
Yes No
Have you EVER received any type of military,
paramilitary, or weapons training?
34.
Yes No
Have you EVER unlawfully voted in a United States
Federal, state, or local election?
35.
Yes No
Have you EVER claimed to be a U. S. citizen (in writing or in any other way)?
36.
Yes No
37.a. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? Yes No
Have you EVER used any person under 15 years of age to take part in hostilities or to help or provide services to people in combat?
37.b.
Yes No
Have you EVER committed or conspired to commit
human trafficking offenses, as defined in the section 103 of the Victims of Trafficking and Violence Protection Act of 2000, in the United States or outside the United States? 38.a.
Yes No
Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded with a human trafficker?
38.b.
Yes No
Are you NOW the spouse or child of an alien who
committed or conspired to commit human trafficking offenses?
38.c.
Yes No
Are you NOW the spouse or child of, or are you yourself, an alien who knowingly aided, abetted, assisted,
conspired, or colluded with a human trafficker?
38.d.
Yes No
Within the previous five years, have you EVER obtained any financial or other benefit from the human trafficking activity of your spouse (including former spouses) or parents, and you knew, or reasonably should have
known, that the financial or other benefit that you received resulted from such human trafficking?
38.e.
Yes No
Are you NOW or have you EVER engaged in money
laundering as described in section 1956 or 1957 of Title 18, United States Code?
39.a.
Yes No
Are you NOW or have you EVER been a knowing aider, abettor, assister, conspirator, or colluder with others in money laundering?
39.b.
Yes No
Have you EVER been responsible for or directly carried out particularly severe violations of religious freedom, as defined in section 3 of the International Religious Freedom Act of 1998 (22 U.S.C. section 6402) while serving as a foreign government official?
40.
Yes No
Has an immigration judge or the Board of Immigration Appeals EVER determined that you filed a frivolous asylum application in the past?
41.
Yes No
Part 8. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-821 Instructions before completing this part. You must file Form I-821 while in the United States.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.
prepared this application for me based only upon
information I provided or authorized.
2. At my request, the preparer named in Part 10.,
a language in which I am fluent, and I understood
everything.
The interpreter named in Part 9. read to me every
question and instruction on this application and my answer to every question in
1.b.
I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question.
1.a.
Electronic
Form
Only
Form I-821 04/01/24 Electronic Form Only Page 11 of 13 Part 8. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
Applicant's Contact Information
********************@*****.***
5. Applicant's Email Address (if any)
4. Applicant's Mobile Telephone Number (if any)
3. Applicant's Daytime Telephone Number
Applicant's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this application, in supporting documents, and in my USCIS
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