Page 4 of 7Form I-765 05/31/18
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 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.
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
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
Date of Signature (mm/dd/yyyy)7.b.
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.
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
Part 4. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Business or Organization Name (if any)
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information about the interpreter.