Form I-821 Form

I-821 Form: Application for Temporary Protected Status
Confirmation Receipt
USCIS Receipt Number:
Concurrent Filing Identification Number:
ASC Fingerprint Code:
Date of Submission:
First Name:
Middle Name:
Family Name:
Organization Name:
Filing Fee: $
Biometrics Fee: $
Total Amount Paid: $
Paid by:

EAC1280004500
3554658
11/12/2011
GREGORIO
E
BONILLA
0.00
85.00
85.00
Visa

Thank you for filing your USCIS benefit application electronically. Your application will be electronically transmitted to the

USCIS location at the address below for processing. You will receive an official Receipt Notice (Form I-797) within 7-10 days by standard mail with the same Receipt Number found at the top of this page.
Next Steps:
Provide the following information:
I am a national of (or an alien having no nationality, who last habitually resided in the state of):
HONDURAS

I entered the United States on the following date (provide month/day/year), and have resided in the United States since that time.
12/22/1998

2. To be eligible for Temporary Protected Status, you must be admissible as an immigrant to the United States, with certain exceptions. If any of the questions beginning below on this page and continuing on Pages 3, 4, and 5 apply to you, describe the circumstances and include a full explanation on a separate sheet(s) of paper. Use the number 2 before each letter referring to the specific question
(2a, 2b, etc).
If you were ever arrested, provide the disposition (outcome) for all arrests. For example, "case dismissed" from the appropriate authority. NOTE: For information about waivers concerning the grounds of inadmissibility, see Page 5.
2a. Have you been convicted of any felony or two or more misdemeanors committed in the United States?
Yes

No

2b. (i) Have you ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race,
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?

Yes

No

2s. Have you EVER assisted 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?

Yes

No

2t. Have you ever received any type of military, paramilitary, or weapons training?

Yes

No

NOTE ABOUT WAIVERS: You may be eligible for a waiver of the grounds described in the questions: 2e; 2f; 2g; 2h; 2i; 2j;
2k; 2l; 2m; 2n or 2o. The Form I-601 is the USCIS application used to request a waiver. The form is available at local USCIS offices, on our website at www.uscis.gov or by calling the USCIS toll-free forms line at 1-800-870-3676.

Part 5.

Signature.

Read the information on penalties in the instructions before completing this section. If someone helped you prepare this petition, he or she must complete Part 6.

Applicant's Statement (check one):
I can read and understand English, and have read and understand each and every question and instruction on this form,