I-765V Application for Employment Authorization for Abused Noni

Application for Employment Authorization for
Abused Nonimmigrant Spouse

USCIS
Form I-765V

Department of Homeland Security
U.S. Citizenship and Immigration Services

Authorization/Extension
Valid From

OMB No. 1615-0137
Expires 01/31/2019

Fee Stamp

Action Block

Authorization/Extension
For
Valid Through
USCIS
Use
Only Remarks

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Production
11/14/2017

To be completed by an
Attorney or Accredited
Representative (if any).

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Reason for Applying

Other Names Used (if any)

I am applying for:

Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 9.
Additional Information.

1.a.

Initial permission to accept employment.

1.b.

Replacement of lost, stolen, or damaged employment
authorization document, or correction of my
employment authorization document NOT DUE to
U.S. Citizenship and Immigration Services (USCIS)
error.

1.c.

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

NOTE: Replacement (correction) of an employment
authorization document due to USCIS error does not
require a new Form I-765V. Refer to the Form
I-765V Instructions for further details.

2.c. Middle Name

Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)

NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
mailing address.

Safe Mailing Address

3.a. In Care Of Name (if any)

Part 2. Information About You
Your Full Name

3.b. Street Number
and Name

NOTE: USCIS will issue your card in this name.

3.c.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

3.d. City or Town

1.c. Middle Name

4.

Apt.

3.e. State

Ste.

3.f.

Flr.

ZIP Code

Is your current U.S. physical address the same as your
safe mailing address?
Yes
No
If you answered "No" to Item Number 4., provide your
U.S. physical address in Item Numbers 5.a. - 5.e.

Form I-765V 01/19/17 N

Page 1 of 7

Part 2. Information About You (continued)

Mother's Name
Provide your mother's birth name.

U.S. Physical Address

12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)

5.a. Street Number
and Name
5.b.

Apt.

Ste.

Your Country or Countries of Citizenship or
Nationality

5.c. City or Town

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5.e. ZIP Code

5.d. State

Other Information
6.

Flr.

List all countries where you are currently a citizen or national.
If you need extra space to complete this item, use the space
provided in Part 9. Additional Information.

Alien Registration Number (A-Number) (if any)

13.a. Country

► A-

7.

USCIS Online Account Number (if any)
►

13.b. Country

8.a. Has the Social Security Administration (SSA) ever
officially issued a Social Security card to you?
Yes

Place of Birth

No

NOTE: If you answered "No" to Item Number 8.a., skip to
Item Number 9. If you answered "Yes" to Item Number 8.a.,
provide the information requested in Item Number 8.b.

14.a. City/Town/Village of Birth

14.b. State/Province of Birth

8.b. Provide your Social Security number (SSN) (if any)

14.c. Country of Birth

►

9.

Do you want the SSA to issue you a Social Security card?
(You must also answer “Yes” to Item Number 10.,
Consent for Disclosure, to receive a card.)
Yes

No

15.

Date of Birth (mm/dd/yyyy)

16.

Gender

Male

Female

NOTE: If you answered "No" to Item Number 9., skip to
Item Number 13. If you answered “Yes” to Item Number 9.,
you must also answer "Yes" to Item Number 10.

Information About Your Most Recently Filed
Employment Authorization

10.

17.

Consent for Disclosure: I authorize disclosure of
information from this application to the SSA as required
for the purpose of assigning me an SSN and issuing me a
Social Security card.
Yes
No

NOTE: If you answered "Yes" to Item Numbers 9. - 10.,
provide the information requested in Item Numbers 11.a. - 12.b.

Father's Name
Provide your father's birth name.
11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)

Form I-765V 01/19/17 N

Have you previously applied for employment authorization
or for an Employment Authorization Document (EAD)?
Yes (Complete Item Numbers 18.a. - 18.d.)
No (Proceed to Item Number 19.)

18.a. Receipt Number of Your Most Recently Filed Application
for Employment Authorization
►
18.b. Which USCIS office adjudicated this application?

18.c. Enter the date USCIS approved or denied this
application (mm/dd/yyyy)

Page 2 of 7

Part 2. Information About You (continued)

Part 3. Biographic Information

18.d. Was this application approved or denied?
Approved

1.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

2.

Race (Select all applicable boxes)
American Indian or Alaska Native
Asian
Black or African American

Denied

Attach all documentation from your previous employment
authorization (for example, a copy of your previous EAD,
approval notice, or denial notice).

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Information About Your Last Arrival in the United
States
19.

Place of Your Last Admission Into the United States

20.

Date of Your Last Admission Into the United
States, On or About (mm/dd/yyyy)

21.

Your Immigration Status When You Were Last Admitted
Into the United States (for example, A-2, E-3, G-1, H-4)

22.a. Form I-94 Arrival-Departure Record Number (if any)
►

Native Hawaiian or Other Pacific Islander
White

3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

22.b. Date Your Current Status Expired or Will Expire, As
Shown On Form I-94 (mm/dd/yyyy)
22.c. Passport Number

22.d. Travel Document Number

Feet

Inches
Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red
Unknown/Other

Part 4. Information About Your Spouse

For all of the questions in Part 4., provide the following
information, if known.

22.e. Country That Issued Your Passport or Travel Document

22.f. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
23.

24.

Your Current Immigration Status (for example, A-2, E-3,
G-1, H-4, deferred action, no lawful status)

Eligibility Category. Refer to the Who May File Form
I-765V section of the Form I-765V Instructions to
determine the appropriate eligibility category for you. In
the space below, enter the letter and number for your
eligibility category. (For example, (c)(27), (c)(28), (c)
(29), (c)(30).)

2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

U.S. Physical Address
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

4.c. City or Town
4.d. State

Form I-765V 01/19/17 N

4.e. ZIP Code

Page 3 of 7

Part 4. Information About Your Spouse
(continued)

3.a.

Widowed

3.b. Date of Spouse's Death (mm/dd/yyyy)

Other Information
5.

Alien Registration Number (A-Number) (if any)
► A-

6.

4.

Separated

5.a.

Marriage Annulled

USCIS Online Account Number (if any)

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5.b. Date of Annulment (mm/dd/yyyy)

►

7.a. Form I-94 Arrival-Departure Record Number (if any)
►
7.b. Passport Number

Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

7.c. Travel Document Number

NOTE: Read the Penalties section of the Form I-765V
Instructions before completing this section. You must file Form
I-765V while in the United States.

7.d. Country That Issued Your Spouse's Passport or Travel
Document

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.

7.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
8.

1.a.

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.b.

The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in

Your Spouse's Nonimmigrant Status (Select only one box)
A-1

A-2

A-3

E-3

G-1

G-2

G-3

G-4

G-5

H-1B

H-1B1

H-1C

H-2A

H-2B

H-2R

H-3

Other (Use the space provided in Part 9.
Additional Information)

a language in which I am fluent, and I understood
everything.

2.

prepared this application for me based only upon
information I provided or authorized.

Your Current Marital Status (Select only one box)
Married

1.b. Date of Marriage (mm/dd/yyyy)

At my request, the preparer named in Part 8.,
,

Part 5. Marriage Information

1.a.

,

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

1.c. City or Town of Marriage

1.d.

2.a.

Country of Marriage

Divorced

2.b. Date of Divorce (mm/dd/yyyy)

Form I-765V 01/19/17 N

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Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)

Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

Applicant's Declaration and 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 and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

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I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:

3.b.

1)

I reviewed and understood all of the information
contained in, and submitted with, my application; and

3.c. City or Town

2)

All of this information was complete, true, and correct at
the time of filing.

3.d. State

I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.

Applicant's Signature

6.a. Applicant's Signature (sign in ink)

3.a. Street Number
and Name

3.f.

Apt.

Ste.

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

6.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.

Form I-765V 01/19/17 N

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Preparer's Contact Information

Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and

,

which is the same language specified in Part 6., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.

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11/14/2017

Interpreter's Signature

7.a. Interpreter's Signature (sign in ink)

7.b. Date of Signature (mm/dd/yyyy)

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name

Preparer's Statement

7.a.

I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.

NOTE: If you are an attorney or accredited
representative, you may need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and informed
me that he or she understands all of the information contained
in, and submitted with, his or her application, including the
Applicant's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.

Preparer's Signature
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

8.a. Preparer's Signature (sign in ink)

8.b. Date of Signature (mm/dd/yyyy)

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-765V 01/19/17 N

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5.a. Page Number

Part 9. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

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A-Number (if any)
► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-765V 01/19/17 N

4.c. Item Number

7.a. Page Number

7.d.

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