Pia

USCIS Privacy Act Statement
Form I-765

AUTHORITIES: The information requested on this application, and the associated evidence, is
collected pursuant to the Immigration and Nationality Act, 8 U.S.C. § 1324a, as amended.
PURPOSE: The primary purpose for providing the requested information on this form is to
determine eligibility for certain aliens who are temporarily in the United States requesting an
Employment Authorization Document (EAD).
DISCLOSURE: The information you provide is voluntary. However, failure to provide the
requested information, and any requested evidence, may delay a final decision or result in the
denial of your benefit request.
ROUTINE USES: The information you provide on this benefit application may be shared with
other federal, state, local, and foreign government agencies and authorized organizations in
accordance with approved routine uses, as described in the associated published system of
records notices [DHS-USCIS-001 – Alien File, Index, and National File Tracking System; DHSUSCIS-007 – Benefit Information System; and DHS/USCIS-010 – Asylum Information and PreScreening, which can be found at www.dhs.gov/privacy]. The information may also be made
available, as appropriate for law enforcement purposes or in the interest of national security.