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Ck. For Government use only. Fee Stamp 212 (a) (6) 212 (a) (1) 212 (a) (2) 212 (a) (3) TPS Applicant: 212 (a) (9) (specify ground(s)) A. Information about applicant 1. Family Name (Surname In CAPS) 11. Applicant was previously in the United States, as follows: (First) (Middle) 2. Address (Number and Street) From (Date) To (Date) Immigration Status (Apartment Number) 3. (Town or City) City and State (Zip/Postal Code) (State/Country) Telephone Number 4. Date of Birth (mm/dd/yyyy).

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