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

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

Action Block

Fee Stamp

For USCIS Use Only

AEAD Code Assigned: (c)
Initial Receipt
Resubmitted

Application
Approved

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PRODUCTION
05/18/2020
Completed
Approved
Denied
Returned

Relocated

Remarks

Received
Sent

Authorization/Extension Valid From

Application Denied

Authorization/Extension Valid To

Select this box if
Form G-28 is
attached.

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

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. Information About You
1.

I am applying for:

Initial permission to accept employment.

Replacement. (Lost, stolen, mutilated card, or my
card contains incorrect information not attributed to
U.S. Citizenship and Immigration Services (USCIS)
error.)
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
2.

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

3.

USCIS Online Account Number (if any)
►

4.

U.S. Social Security Number (if any)

Other Names Used (if any)

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 8.
Additional Information.
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

6.c. Middle Name

Safe Mailing Address

NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
mailing address.
7.a. In Care Of Name (if any)

►

Your Full Name
NOTE: USCIS will issue your card in this name.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name

7.b. Street Number
and Name
7.c. Apt.

Ste.

Flr.

7.d. City or Town
7.e. State
8.

7.f.

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 8., provide your
U.S. physical address in Item Numbers 9.a. - 9.e.

Form I-765V 01/19/17 N

Page 1 of 6

19.b. Date Current Status Expired or Will Expire, as shown on
Form I-94 (mm/dd/yyyy)

Part 1. Information About You (continued)
U.S. Physical Address

19.c. Passport Number

9.a. Street Number
and Name
9.b. Apt.

19.d. Travel Document Number

Ste.

Flr.

19.e. Country of Issuance for Passport or Travel Document

9.c. City or Town
9.d. State

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

9.e. ZIP Code

Other Information
10.

Sex

Male

11.

Date of Birth (mm/dd/yyyy)

20.

Current Immigration Status (for example, A-2, E-3, G-1,
H-4, No Lawful Status)

21.

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 this
application. In the space below, enter the letter and
number for your eligibility category. (For example,
(c)(27), (c)(28), (c)(29), (c)(30)).

Female

12.a. City or Town of Birth

12.b. State or Province of Birth

12.c. Country of Birth

Part 2. Biographic Information

13.

Country of Citizenship or Nationality

14.

Have you EVER applied for employment authorization
from USCIS?
Yes
No

1.

Ethnicity (Select only one box)
Hispanic or Latino

Not Hispanic or Latino

2.

If you answered "Yes" to Item Number 14., provide the
information requested in Item Numbers 15.a. - 15.b. for
your most recent application.

Race (Select all applicable boxes)
White

Asian

Black or African American

15.a. Which USCIS Office?

American Indian or Alaska Native

15.b. What was the result?

Approved

NOTE: Attach all documentation from your previous
employment authorization.
16.

Place of Last Entry into the United States

17.

Date of Last Entry into United States, on or about
(mm/dd/yyyy)

18.

Immigration Status of Last Entry (for example, A-2, E-3,
G-1, H-4)

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

Form I-765V 01/19/17 N

Native Hawaiian or Other Pacific Islander

Denied
3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

Feet

Inches
Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

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

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Page 2 of 6

Part 3. Information About Your Spouse

Part 4. Marriage Information

Provide the following information, if known.

Your Current Marital Status (Select only one box)

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

1.a.

Married

1.b. Date of Marriage (mm/dd/yyyy)
1.c. City or Town of Marriage

1.c. Middle Name

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2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

1.d.

2.a.

Country of Marriage

Divorced

U.S. Physical Address

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

4.a. Street Number
and Name

3.a.

4.b. Apt.

Ste.

Flr.

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

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

Widowed

4.e. ZIP Code

4.

Separated

5.a.

Marriage Annulled

Other Information

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

5.

A-Number (if any)
► A-

6.

USCIS Online Account Number (if any)
►

Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

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

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

7.b. Passport Number

Applicant's Statement

7.c. Travel Document Number
7.d. Country of Issuance for Passport or Travel Document

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
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 6. read to me every
question and instruction on this application and my
answer to every question in

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

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 8.
Additional Information)

,
a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 7.,
,
prepared this application for me based only upon
information I provided or authorized.

Form I-765V 01/19/17 N

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Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Applicant's Contact Information
3.

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

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

Applicant's Daytime Telephone Number
2.

Interpreter's Business or Organization Name (if any)

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4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Interpreter's Mailing Address

3.a. Street Number
and Name

3.b. Apt.

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 and all information from any of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.

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.

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.

Ste.

Flr.

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

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)

Applicant's Signature

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

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

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

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.

Part 6. Interpreter's Contact Information,
Certification, and Signature

,

which is the same language specified in Part 5., 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.

Provide the following information about the interpreter.

Form I-765V 01/19/17 N

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Part 6. Interpreter's Contact Information,
Certification, and Signature (continued)

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
does not extend beyond the
extends
preparation of this application.

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

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

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Part 7. 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

NOTE: If you are an attorney or accredited
representative, you may be obliged 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 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

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

3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

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

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Form I-765V 01/19/17 N

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5.a. Page Number

Part 8. 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.

5.b. Part Number

5.c. Item Number

5.d.

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

1.c. Middle Name
2.

6.a. Page Number

A-Number (if any)

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

► A-

3.a. Page Number

3.d.

3.b. Part Number

3.c. Item Number

6.d.

7.a. Page Number

4.a. Page Number

4.b. Part Number

4.c. Item Number

7.d.

4.d.

Form I-765V 01/19/17 N

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