Form I-765WS Work Sheet

Form I-765 Worksheet
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-765WS
OMB No. 1615-0040
Expires 04/30/2013

If you are applying for employment authorization under the (c)(14), Deferred Action, or (c)(33), Consideration of Deferred Action
for Childhood Arrivals, eligibility categories, complete this worksheet to establish your economic need for employment pursuant to
8 CFR § 274a.12(e). It is not necessary to submit supporting documentation, though it will be accepted and reviewed if you choose to
submit it.

Part 1. Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Not for
Production
08/02/12
Final

Part 2. Financial Information
2.

My current annual income is:

$

3.

My current annual expenses are:

$

4.

The current value of my assets is: $

Part 3. Additional Information

If you would like to provide an explanation of the above information, please use the space below.

Form I-765WS Worksheet 08/08/12

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