Page 4 of 7Form I-765 Edition 08/25/20
NOTE: If you answered “Yes” to Item Number 31.b.,
refer to Employment-Based Nonimmigrant Categories,
Items 8. - 9., in the Who May File Form I-765 section of
the Form I-765 Instructions for information about
providing court dispositions.
If you entered the eligibility category (c)(35) or (c)(36) in
Item Number 27., have you EVER been arrested for
and/or convicted of any crime? Yes No
Part 2. Information About You (continued)
(c)(35) and (c)(36) Eligibility Category. If you entered
the eligibility category (c)(35) in Item Number 27., please
provide the receipt number of your Form I-797 Notice for
Form I-140, Immigrant Petition for Alien Worker. If you
entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or
parent's Form I-797 Notice for Form I-140.
The interpreter named in Part 4. read to me every
question and instruction on this application and my
answer to every question in
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.
a language in which I am fluent, and I understood
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
NOTE: Read the Penalties section of the Form I-765
Instructions before completing this section. You must file
Form I-765 while in the United States.
At my request, the preparer named in Part 5.,
prepared this application for me based only upon
information I provided or authorized.
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Mobile Telephone Number (if any)4.
Applicant's Email Address (if any)5.
Select this box if you are a Salvadoran or Guatemalan
national eligible for benefits under the ABC
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.
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.
If you answered “Yes” to Item Number 30.c., provide the
30.d. Date you presented yourself to DHS
NOTE: Refer to the Special Filing Instructions for Those
With Pending Asylum Applications (c)(8) section of the Form
I-765 Instructions for more information.
30.e. Location where you presented yourself to DHS
30.f. Country of claimed persecution
30.g. Provide an explanation for why you did not enter the
United States lawfully through a U.S. port of entry. If
you need extra space to complete this item, use the space
provided in Part 6. Additional Information.