I-821 Application for Temporary Protected Status Personal Statement Template

[Your Full Name]
[A-Number (if any)]
[Your Street Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]

[Date]

U.S. Citizenship and Immigration Services
[USCIS Service Center / TPS Address]

Re: Form I-821, Application for Temporary Protected Status
Personal Statement of [Your Full Name], DOB: [MM/DD/YYYY]

1. Introduction

I, [Your Full Name], was born on [Date of Birth] in [City, Country]. I am submitting this personal statement in support of my Form I-821, Application for Temporary Protected Status.

In this statement, I provide information about my background, my connection to [TPS-Designated Country], my residence in the United States, and my concerns about returning to [Country] at this time.

2. Personal Background

Full Name: [Your Full Name]
Other Names Used: [Other Names or “None”]
Date of Birth: [MM/DD/YYYY]
Place of Birth: [City, Country]
Citizenship/Nationality: [Country]

Ethnic Group (if relevant): [Ethnic Group or “N/A”]
Religion or Belief System (if relevant): [Religion / Belief or “N/A”]
Primary Language(s): [Language(s)]

Education: [Schools Attended and Highest Level of Education]
Occupation in Home Country: [Job Title / Main Work Activities]

3. Family Background

Parents:

• [Parent’s Name], [Date of Birth], [Citizenship / Current Location]

• [Parent’s Name], [Date of Birth], [Citizenship / Current Location]

Spouse or Partner (if any):

• Name: [Spouse/Partner Name]

• Date of Birth: [MM/DD/YYYY]

• Citizenship/Nationality: [Country]

• Current Location and Status: [Location / Status]

Children (if any):

• [Child’s Name], DOB: [MM/DD/YYYY], [Country of Birth], [Current Location and Status]

• [Child’s Name], DOB: [MM/DD/YYYY], [Country of Birth], [Current Location and Status]

Other Close Family Members:
[Names, relationships, and current locations of siblings, grandparents, or other important relatives.]

4. Connection to the TPS-Designated Country

Country for TPS: [Country Name]

Place of Upbringing: [City/Town, Region, Country]
How Long You Lived There: [Years]

Family and Community Ties in [Country]:
[Short description of your family, community, or work life in the TPS-designated country.]

Any Previous Moves Within [Country]:
[Description of major internal moves or relocations, with approximate dates.]

5. Entry to the United States and Immigration History

Date of Last Departure from [Country]: [Date]
Countries Transited Before the United States (if any): [Countries / “None”]

Date of Arrival in the United States: [Date]
Place of Arrival: [City, State or Port of Entry]

Manner of Entry: [With Visa / Visa Waiver / Without Inspection / Other]
Class of Admission (if any): [Class of Admission or “N/A”]

Immigration History in the United States:

• Prior Applications or Petitions Filed: [Form Type – Receipt Number – Date or “None”]

• Prior Removal, Voluntary Departure, or Immigration Court Proceedings: [Description or “None”]

6. Residence and Presence in the United States

Current Address: [Street, City, State, ZIP Code]

Residence History in the United States:

• From [MM/YYYY] to [MM/YYYY]: [Address, City, State]

• From [MM/YYYY] to [MM/YYYY]: [Address, City, State]

• From [MM/YYYY] to Present: [Address, City, State]

Employment, Study, or Other Activities in the United States:
[Description of work, school, or other significant activities, with approximate dates.]

Departures from the United States (if any):

• Date(s) of Departure: [Date(s) or “None”]

• Date(s) of Return: [Date(s)]

• Purpose of Travel: [Short Description]

7. Conditions in the TPS-Designated Country

General Conditions in [Country]:
[Short description of conflict, disaster, or other extraordinary and temporary conditions affecting your country.]

Conditions in Your Home Region or City:
[Description of how these conditions affect your specific area, such as security, infrastructure, economy, or basic services.]

Effects on You and Your Family:
[Description of how conditions in the country impact your safety, access to work, health care, housing, education, or daily life.]

8. Reasons You Are Applying for TPS

Reasons You Cannot Safely or Reasonably Return to [Country] at This Time:
[Description of your concerns about returning, including safety, violence, disaster-related issues, or severe disruptions in basic living conditions.]

Impact on Your Family if You Must Return:
[Description of how your return would affect you, your spouse, children, parents, or other close relatives, both in the United States and abroad.]

Any Prior Harm or Threats in [Country] (if applicable):
[Brief description of any specific incidents of harm, threats, or serious problems you personally experienced.]

9. Life in the United States

Current Household Members in the United States:
[Names, relationships, and immigration or citizenship status, if known.]

Work and Community Involvement:
[Description of your work, volunteering, religious or community participation, and support you provide to family or community members.]

Responsibilities and Support You Provide:
[Description of childcare, elder care, financial support, or other important responsibilities you have in the United States.]

10. Hardship If TPS Is Not Granted

Potential Hardship to You:
[Description of how denial of TPS would affect your safety, health, livelihood, and access to basic needs.]

Potential Hardship to Your Family:
[Description of hardship to your spouse, children, or other close relatives in the United States or abroad if you must return or if you cannot lawfully remain or work.]

11. Supporting Evidence

I am submitting, or will submit, supporting documents with my Form I-821, which may include:

• Copy of my passport or national identity document from [Country]

• Birth certificate or other civil documents

• Entry and travel documents (visa, I-94, tickets, or other records, if available)

• Proof of residence in the United States (leases, bills, school records, employment records, tax records, or other documents)

• Documents about conditions in [Country] (reports, news articles, or other reliable information)

• Documents about my family relationships and responsibilities (marriage certificates, birth certificates of children, affidavits, or letters)

12. Closing Declaration

I respectfully request that USCIS approve my Form I-821, Application for Temporary Protected Status. I wish to remain lawfully in the United States during the period that [Country] is designated for TPS so that I can live and support myself and my family without being returned to dangerous or unstable conditions.

I declare under penalty of perjury under the laws of the United States of America that the information in this personal statement and in my Form I-821 and supporting documents is true and correct to the best of my knowledge and belief.

Executed on [Day] [Month], [Year], in [City, State].

[Your Full Name]
[Signature, if printed]
[Date]