Form I-765V 01/19/17 N Page 4 of 6
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
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)6.b.
Applicant's Signature (sign in ink)6.a.
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.
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)
Interpreter's Mailing Address
3.c. City or Town
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)