Rev. 6/9/14

DACA Clinic Check-Out List for Renewal Requestors

(for Attorneys and BIA Accredited Representatives)

Requestor’s Name: ______Date:______

DACA Expiration Date: ______

Form I-821D

Part 1. Information about You

___The “Renewal Request” box is checked

___Requestor’s name and mailing address are written correctly

___Confirm whether requestor is now or has been in removal proceedings

___Verify that social security number was officially issued to the requestor by

the Social Security Administration

___Verify any other names used

___Processing Information is filled in correctly

Part 2. Residence and Travel Information

___ Requestor continuously resided in U.S. since last submitted Form

I-821D.

___ Requestor listed (to the best of their knowledge) all of their addresses since

submitted the last Form I-821D that was approved.

___ Requestor listed all absences since submitted last Form I-821D that

was approved.

___ Confirm that requestor did not travel abroad after receiving without

advance parole

Part 4. Criminal, National Security and Public Safety Information

___ Verify whether there are any new contacts with police or activities that may

deem the requestor a threat to public safety since s/he submitted last

Form I-821D. If there are NEW incidents, refer the requestor to an attorney

or BIA accredited representative for further individual consultation.

Part 5. Statement, Certification, Signature, and Contact Information of the Requestor

___ The requestor checked either 1.a. or 1.b.

___ The requestor signed the application.

Part 6. Contact Information, Certification, and Signature of the Interpreter

___ If the requestor checked 1.b., the interpreter completed part 6.

Part 7. Contact Information, Declaration, and Signature of Person Preparing Request

___ Person who assisted preparer provided name, mailing address of sponsoring

organization, contact information, and signed declaration.

Part 8. Additional Information

___Verify that information in this section clearly indicates the corresponding

page, part and item numbers.

___Requestor signed and dated this page and any other addendum page

Form I-765, Employment Authorization Application

___ The entire form is completed (except question 17, which is left blank)

___ Verify that the “Renewal of my permission to accept employment” box is

checked

___ Verify all information with requestor

___ Verify that the names (last, first, middle and other names used) and the

mailing address are the same as those on Form I-821D

___ Question 15 says “DACA Recipient”

___ Question 16 is marked as (c)(33)

Form I-765WS, Employment Authorization Worksheet

___ Make sure all parts are completed, including that “current annual income”

refers only to the income of the requestor.

______

Signature of Check-Out Legal Volunteer Date

______

Full Name of Check-Out Legal Volunteer Date

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