Fillable I-765v USCIS Form I-765V

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I-765v USCIS Form I-765V

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The I-765v USCIS Form I-765V form is 6 pages long and contains:

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Country of origin: US
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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-765V 01/19/17 N Page 1 of 6
For USCIS Use Only
Application for Employment Authorization for
Abused Nonimmigrant Spouse
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-765V
OMB No. 1615-0137
Expires 01/31/2019
Fee Stamp
Initial Receipt
Resubmitted
Action Block
Application
Approved
A-
EAD Code Assigned: (c)
Completed
Approved
Denied
Returned
Relocated
Received
Sent
Remarks
Application Denied
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)
To be completed by an
Attorney or Accredited
Representative (if any).
Part 1. Information About You
START HERE - Type or print in black ink.►
Initial permission to accept employment.
I am applying for:
Replacement. (Lost, stolen, mutilated card, or my
card contains incorrect information not attributed to
U.S. Citizenship and Immigration Services (USCIS)
error.)
1.
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
USCIS Online Account Number (if any)3.
►
►
A-
2. Alien Registration Number (A-Number) (if any)
►
U.S. Social Security Number (if any)4.
Your Full Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
NOTE: USCIS will issue your card in this name.
5.a.
5.b.
5.c.
6.b.
6.c.
6.a.
Other Names Used (if any)
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
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 7.
Additional Information.
7.a.
7.b.
7.c.
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.
Street Number
and Name
7.d. City or Town
7.e.
State
7.f.
ZIP Code
Flr.Ste.Apt.
In Care Of Name (if any)
If you answered "No" to Item Number 8., provide your
U.S. physical address in Item Numbers 9.a. - 9.e.
8. Is your current U.S. physical address the same as your
safe mailing address?
Yes No
Authorization/Extension Valid To
Authorization/Extension Valid From
Form I-765V 01/19/17 N Page 2 of 6
Part 1. Information About You (continued)
U.S. Physical Address
9.a.
Street Number
and Name
9.b.
9.c. City or Town
9.d.
State
9.e.
ZIP Code
Flr.Ste.
Apt.
Other Information
Sex Female
Male10.
Date of Birth (mm/dd/yyyy)11.
13.
Country of Citizenship or Nationality
12.a. City or Town of Birth
State or Province of Birth
Country of Birth
12.b.
12.c.
Have you EVER applied for employment authorization
from USCIS?
Yes No
14.
If you answered "Yes" to Item Number 14., provide the
information requested in Item Numbers 15.a. - 15.b. for
your most recent application.
17. Date of Last Entry into United States, on or about
(mm/dd/yyyy)
Place of Last Entry into the United States16.
Which USCIS Office?15.a.
What was the result?
Approved Denied15.b.
NOTE: Attach all documentation from your previous
employment authorization.
Immigration Status of Last Entry (for example, A-2, E-3,
G-1, H-4)
18.
►
Form I-94 Arrival-Departure Record Number (if any)19.a.
19.f.
Travel Document Number19.d.
Country of Issuance for Passport or Travel Document
19.e.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Current Immigration Status (for example, A-2, E-3, G-1,
H-4, No Lawful Status)
20.
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)).
21.
Part 2. Information About Your Spouse
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
2. Date of Birth (mm/dd/yyyy)
3.
Country of Birth
Provide the following information, if known.
Passport Number
19.c.
4.a.
Street Number
and Name
4.b.
4.c. City or Town
4.d.
State
4.e.
ZIP Code
Flr.Ste.
Apt.
U.S. Physical Address
A-Number (if any)5.
►
A-
Other Information
Date Current Status Expired or Will Expire, as shown on
Form I-94 (mm/dd/yyyy)
19.b.
Form I-765V 01/19/17 N Page 3 of 6
Country of Issuance for Passport or Travel Document7.d.
Part 2. Information About Your Spouse
(continued)
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 7.
8.
7.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Additional Information)
Part 3. Marriage Information
1.a.
Your Current Marital Status (Select only one box)
Date of Marriage (mm/dd/yyyy)
Married
1.b.
City or Town of Marriage
1.c.
Country of Marriage1.d.
Passport Number7.b.
►
Form I-94 Arrival-Departure Record Number (if any)7.a.
Travel Document Number7.c.
3.a.
Date of Divorce (mm/dd/yyyy)
Date of Spouse's Death
(mm/dd/yyyy)
Widowed
2.b.
3.b.
4.
Separated
5.a.
Date of Annulment (mm/dd/yyyy)
Marriage Annulled
5.b.
2.a.
Divorced
The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
2. At my request, the preparer named in Part 6.,
prepared this application for me based only upon
information I provided or authorized.
,
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
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.a.
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
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.
Applicant's Statement
USCIS Online Account Number (if any)6.
►
Applicant's Mobile Telephone Number (if any)4.
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Email Address (if any)5.
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.
Form I-765V 01/19/17 N Page 4 of 6
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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.
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature (sign in ink)6.a.
Applicant's Signature
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.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Given Name (First Name)1.b.
Part 5. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information about the interpreter.
Interpreter's Daytime Telephone Number4.
Interpreter's Email Address (if any)6.
Interpreter's Contact Information
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Certification
I am fluent in English and
which is the same language specified in Part 4., 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.
I certify, under penalty of perjury, that:
,
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)
7.a.
Interpreter's Signature
Interpreter's Mailing Address
Street Number
and Name
3.a.
3.b.
Apt.
Flr.Ste.
3.c. City or Town
3.g.
Postal Code
3.h. Country
3.d.
State
3.e.
ZIP Code
3.f.
Province
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Given Name (First Name)1.b.
2. Preparer's Business or Organization Name
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
Form I-765V 01/19/17 N Page 5 of 6
Preparer's Mailing Address
Street Number
and Name
3.a.
3.b.
Apt.
Flr.Ste.
3.c. City or Town
3.g.
Postal Code
3.h. Country
3.d.
State
3.e.
ZIP Code
3.f.
Province
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)5.
Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
Preparer's Statement
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.a.
I am an attorney or accredited representative and
my representation of the applicant in this case
7.b.
preparation of this application.
does not extend beyond the
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.
extends
8.a.
Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Preparer's Certification
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
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.
Form I-765V 01/19/17 N Page 6 of 6
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.
A-Number (if any)
►
A-
3.a.
2.
Page Number 3.b. Part Number
3.c.
Item Number
3.d.
4.a.
Page Number
4.b. Part Number
4.c.
Item Number
4.d.
5.a.
Page Number
5.b. Part Number
5.c.
Item Number
5.d.
6.a.
Page Number 6.b. Part Number
6.c.
Item Number
6.d.
Part Number
7.a.
Page Number 7.b.
7.c.
Item Number
7.d.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Part 7. Additional Information
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I-765v USCIS Form I-765V

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Completed 30 December 2020

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