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 02/28/2013

If you are applying for employment authorization under the (c)(14), Deferred Action, or (c)(33), Consideration of Deferred Action for
Childhood Arrivals, categories, you must complete this worksheet so that USCIS can determine whether you have an economic need
to work. In the spaces provided, please indicate your current annual income, your current annual expenses, and the current total value
of your assets. It is not necessary to submit supporting documentation, though it will be accepted and reviewed if you choose to
submit it. You do not need to include other household members' financial information to establish your own economic necessity.

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

DRAFT
Not for
Production
02/15/2013

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. Explanation

If you would like to provide an explanation regarding your current financial information or your economic need for employment
authorization, please use the space below.

Form I-765WS 02/15/13 N

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