Application for Employment Authorization for Abused Nonimmigrant Spouse

Instructions for 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-xxxx
Expires xx/xx/xxxx

What is the Purpose of Form I-765V?
On January 5, 2006, the Violence Against Women and Department of Justice Reauthorization Act of 2005 (VAWA 2005),
Public Law (Pub. L.) 109-162, became effective. On March 7, 2013, VAWA was reauthorized.

Draft
Not for
Reproduction
01/18/2017

VAWA 2005 amended the Immigration and Nationality Act (INA) by adding a new section 106. The new section 106
provides eligibility for employment authorization for spouses of certain nonimmigrants in cases where the spouse has
been battered or subjected to extreme cruelty.
Employment authorization is a benefit granted for a limited period of time and will not establish eligibility for a lawful
status in the United States. Receiving an Employment Authorization Document (EAD) will have no effect on your
immigration status.
Definitions

Employment Authorization Document (EAD): Form I-688, Form I-688A, Form I-688B, Form I-766, or any successor
document issued by U.S. Citizenship and Immigration Services (USCIS) as evidence that an individual is authorized to
work in the United States.
Renewal EAD: An EAD issued to an eligible applicant upon the expiration of a previous EAD issued under the same
category.
Replacement EAD: An EAD issued to an eligible applicant when the previous EAD issued under the same category was
lost, stolen, or mutilated, or contains erroneous information, such as a misspelled name.

Who May File Form I-765V?

USCIS adjudicates a request for employment authorization by determining whether an applicant has submitted the
required information and documentation, and whether the applicant is eligible. In order to determine your eligibility, you
must identify the category in which you are eligible and fill in that category in Part 1., Item Number 21. on Form I-765V.
(For example, if you are the abused spouse of an H nonimmigrant, type or print (c)(30) in Part 1., Item Number 21.)
Enter only one of the following category numbers on the application.
The INA section 106 employment authorization categories are subdivided as listed below:
1. Abused spouse of an A nonimmigrant – (c)(27).
2. Abused spouse of an E-3 nonimmigrant – (c)(28).
3. Abused spouse of a G nonimmigrant – (c)(29).
4. Abused spouse of an H nonimmigrant – (c)(30).
To be eligible for employment authorization issued under INA section 106 as a battered nonimmigrant spouse, you must
submit credible evidence demonstrating that you:
1. Are the qualifying spouse who accompanied or followed to join a principal nonimmigrant spouse admitted under
INA section 101(a)(15)(A), (E)(iii), (G), or (H). To prove you are in a qualifying marital relationship, you must
demonstrate that you:
A. Are married to a qualifying nonimmigrant spouse; or

Form I-765V Instructions xx/xx/xx

Page 1 of 10

B. Were married to a qualifying nonimmigrant spouse; and
(1) Your spouse died within the two years prior to filing Form I-765V;
(2) Your spouse lost qualifying nonimmigrant status due to an incident of domestic violence; or
(3) Your marriage was terminated within the two years prior to filing Form I-765V and there is a connection
between the termination of the marriage and the battery or extreme cruelty perpetrated by your former spouse;
2. Were last admitted to the United States as a nonimmigrant under INA section 101(a)(15)(A), (E)(iii), (G), or (H);
3. Were battered or subjected to extreme cruelty (or your child was battered or subjected to extreme cruelty) perpetrated
by your nonimmigrant spouse during the marriage and after admission as a nonimmigrant under INA section
101(a)(15)(A), (E)(iii), (G), or (H); and

Draft
Not for
Reproduction
01/18/2017

4. Currently reside in the United States.

NOTE: If you remarry prior to adjudication of Form I-765V, Application for Employment Authorization for Abused
Nonimmigrant Spouse, you will be ineligible for issuance of employment authorization under INA section 106.

General Instructions

USCIS provides forms free of charge through the USCIS website. In order to view, print, or fill out our forms, you should
use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not
have Internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that we mail
a form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Signature. Each application must be properly signed and filed. A signature is acceptable if it is an original signature
or an original signature that has been photocopied, scanned, faxed, or similarly reproduced. For all signatures on this
application, USCIS will not accept a stamped or typewritten name in place of a signature. If you are under 14 years of
age, your parent or legal guardian may sign the application on your behalf. A legal guardian may also sign for a mentally
incompetent person.
Filing Fee. There is no filing fee or biometric services fee for Form I-765V. (See the What Is the Filing Fee section of
these Instructions.)
Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Required
Documentation section of these Instructions.
Biometric Services Appointment. USCIS may require that you appear for an interview or provide fingerprints,
photograph, and/or signature at any time to verify your identity, obtain additional information, and conduct background
and security checks, including a check of criminal history records maintained by the Federal Bureau of Investigation
(FBI), before making a decision on your application, petition, or request. After USCIS receives your application and
ensures it is complete, we will inform you in writing if you need to attend a biometric services appointment. If an
appointment is necessary, the notice will provide you the location of your local or designated USCIS Application Support
Center (ASC) and the date and time of your appointment or, if you are currently overseas, instruct you to contact a U.S.
Embassy, U.S. Consulate, or USCIS office outside the United States to set up an appointment.
If you are required to provide biometrics, at your appointment you must sign an oath reaffirming that:
1. You provided or authorized all information in the application;
2. You reviewed and understood all of the information contained in, and submitted with, your application; and
3. All of this information was complete, true, and correct at the time of filing.
If you fail to attend your biometric services appointment, USCIS may deny your application.

Form I-765V Instructions xx/xx/xx

Page 2 of 10

Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you
must submit an original document. USCIS may request an original document at the time of filing or at any time during
processing of an application, petition, or request. If USCIS requests an original document from you, it will be returned to
you after USCIS determines it no longer needs your original.
NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be
immediately destroyed upon receipt.
Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and that
he or she is competent to translate from the foreign language into English. The certification must include the translator’s
signature. DHS recommends the certification contain the translator’s printed name and the date and the translator’s
contact information.

Draft
Not for
Reproduction
01/18/2017

How to Fill Out Form I-765V

1. Type or print legibly in black ink.

2. If you need extra space to complete any item within this application, use the space provided in Part 7. Additional
Information or attach a separate sheet of paper; type or print your name and Alien Registration Number (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.
3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been
married and the question asks, “Provide the name of your current spouse”), type or print “N/A,” unless otherwise
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many
children do you have” or “How many times have you departed the United States”), type or print “None,” unless
otherwise directed. If you do not know the answer to a question, type or print “unknown,” unless otherwise directed.

Specific Instructions

Part 1. Information About You

Complete this section in its entirety. If you need extra space to provide any additional information within this application,
use the space provided in Part 7. Additional Information.
Item Number 1. Reason for Applying. Select the box that best describes your reason for applying.
Item Number 2. Alien Registration Number (A-Number) (if any). An Alien Registration Number, otherwise known
as an “A-Number,” is typically issued to persons who apply for, or are granted, certain immigration benefits. In addition
to USCIS, U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), Executive
Office for Immigration Review (EOIR), and Department of State (DOS) may also issue an A-Number to certain aliens. If
you were issued an A-Number, type or print it in the spaces provided. If you are renewing your EAD, this number may be
listed as the USCIS Number on the front of the card.
Item Number 3. USCIS Online Account Number (if any). If you have previously filed an application, petition, or
request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),
provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account
Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions,
or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice
issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be
found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The
USCIS Online Account Number is not the same as an A-Number.

Form I-765V Instructions xx/xx/xx

Page 3 of 10

Item Number 4. U.S. Social Security Number (if any). If the Social Security Administration (SSA) ever issued a Social
Security card to you in your name or a previously used name, such as your maiden name, then you must enter the Social
Security number from your card in the space provided. If you do not have a Social Security number issued to you by the
SSA, type or print “none” in the space provided.
Item Numbers 5.a. - 5.c. Your Full Name. Provide your full legal name in the spaces provided as it appears on your
birth certificate or legal change of name document.
Item Numbers 6.a.- 6.c. Other Names Used (if any). Provide all other names you have ever used since birth, including
aliases, maiden name, and nicknames.

Draft
Not for
Reproduction
01/18/2017

Item Numbers 7.a. - 8. Safe Mailing Address. If you do not feel safe receiving correspondence regarding this
application at your residential address, provide an alternate or safe mailing address in Part 1., Item Numbers 7.a. - 7.f.
You may provide a post office box (PO Box) or the address of a friend, your attorney, a community-based organization
that is helping you, or any other address where you can safely and punctually receive mail. If an alternate or safe mailing
address is not provided in Part 1., Item Numbers 7.a. - 7.f., USCIS may use the address of your preparer, if any. If your
safe mailing address is not the same as the address where you currently reside, provide your U.S. physical address in Item
Numbers 9.a. - 9.e.
Item Numbers 9.a. - 9.e. U.S. Physical Address. Provide the physical address where you currently reside in the United
States.
Item Number 10. Sex. Select the box that indicates whether you are male or female.

Item Number 11. Date of Birth. Enter your date of birth using the mm/dd/yyyy format. For example, type or print
October 5, 1967 as 10/05/1967.
Item Numbers 12.a. - 12.c. Place of Birth. Provide the name of the city or town, state or province, and country where
you were born. Provide the name of the country as it was named when you were born, even if the country’s name has
changed or the country no longer exists.
Item Number 13. Country of Citizenship or Nationality. Provide the name of the country where you are currently a
citizen or national.
Item Numbers 14. - 15.b. Prior Employment Authorization (if any). Indicate whether you previously applied for
employment authorization. If you previously applied for employment authorization, provide the USCIS office and the
results of that application.
Item Number 16. Place of Last Entry into the United States. Provide the location where you last entered the United
States.
Item Number 17. Date of Last Entry Into the United States. Provide the date of your most recent arrival into the
United States in the mm/dd/yyyy format.
Item Number 18. Immigration Status at Last Entry. Provide the letter and number that correlates with your
immigration status when you last entered or re-entered the United States.
Item Numbers 19.a. -19.f. Form I-94 Arrival-Departure Record. If CBP or USCIS issued you a Form I-94, ArrivalDeparture Record, provide your Form I-94 number and date that your authorized period of stay expires or expired (as
shown on Form I-94). The Form I-94 number also is known as the Departure Number on some versions of Form I-94.
If you do not know your Form I-94 number, type or print “unknown” in the space provided. If you were never issued a
Form I-94, type or print “none” in the space provided.

Form I-765V Instructions xx/xx/xx

Page 4 of 10

NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have
been issued an electronic Form I-94 by CBP, instead of a paper Form I-94. You may visit the CBP website at
www.cbp.gov/i94 to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service. Some
travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013, with a passport or travel
document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form I-94 from the CBP
website without charge. If your Form I-94 cannot be obtained from the CBP website, it may be obtained by filing Form
I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a
fee for this service.
Passport and Travel Document Numbers. If you used a passport or travel document to travel to the United States, enter
either the passport or travel document information in the appropriate space on the application, even if the passport or
travel document is currently expired.

Draft
Not for
Reproduction
01/18/2017

Item Number 20. Current Immigration Status. Provide the letter and number that correlates with your current
immigration status. If you are present in the U.S. without lawful immigration status, type or print, “No Lawful Status.”
Item Number 21. Eligibility Category. Provide the eligibility category under which you are requesting employment
authorization: (c)(27) – abused spouse of A nonimmigrant, (c)(28) – abused spouse of E-3 nonimmigrant, (c)(29) –
abused spouse of G nonimmigrant, or (c)(30) – abused spouse of H nonimmigrant.
Part 2. Information About Your Spouse

Provide the information requested in this section, if known. If you need extra space to complete this section, use the space
provided in Part 7. Additional Information. If you do not know the answer to a question, type or print “unknown,”
unless otherwise directed. Submit evidence to demonstrate the legal status of your spouse. This may include a copy of
his or her passport, travel document information, or evidence of his or her A-Number.
Although you may not be able to provide documentary evidence of your spouse’s nonimmigrant status, you must provide
some identifying evidence such as name, place of birth, country of birth, date of birth, date of entry into the United States,
Form I-94 Number, employer, etc. USCIS will conduct a search of the appropriate electronic systems to attempt to verify
the qualifying nonimmigrant status of the spouse.
Item Numbers 1.a. - 1.c. Your Spouse’s Full Name. Provide your spouse’s full legal name in the spaces provided. Do
not use nicknames.
Item Number 2. Date of Birth. Type or print your spouse’s date of birth using the mm/dd/yyyy format. For example,
type or print October 5, 1967 as 10/05/1967.
Item Number 3. Country of Birth. Type or print the name of the country where your spouse was born.
Item Numbers 4.a. - 4.e. U.S. Physical Address. Provide the address where your spouse currently resides.
Item Number 5. A-Number (if any). Type or print your spouse’s A-Number. An A-Number is typically issued to
persons who apply for, or are granted, certain immigration benefits. ICE, CBP, EOIR, and DOS, in addition to USCIS,
may issue an A-Number to certain aliens. If your spouse was issued an A-Number, type or print it in the spaces provided.
Item Number 6. USCIS Online Account Number. If your spouse has previously filed an application, petition, or
request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),
provide the USCIS Online Account Number your spouse was issued by the system. The USCIS Online Account Number
is not the same as an A-Number.
Item Numbers 7.a. - 7.e. Form I-94 Arrival-Departure Record. If CBP or USCIS issued your spouse a Form I-94,
Arrival-Departure Record, provide your spouse’s Form I-94 number and date that your spouse’s authorized period of stay
expires or expired (as shown on Form I-94). The Form I-94 number also is known as the Departure Number on some
versions of Form I-94.
Form I-765V Instructions xx/xx/xx

Page 5 of 10

Passport and Travel Document Numbers. If your spouse used a passport or travel document to travel to the United
States, enter either the passport or travel document information (if available) in the appropriate space on the application,
even if the passport or travel document is currently expired.
Item Number 8. Your Spouse’s Nonimmigrant Status. Indicate your spouse’s nonimmigrant status by selecting the
appropriate classification.
Part 3. Marriage Information
Submit a copy of your marriage certificate or other evidence to demonstrate that you have a qualifying relationship with
your spouse listed in Part 2.

Draft
Not for
Reproduction
01/18/2017

Item Numbers 1.a. - 5.b. Your Current Marital Status. Select only one box and provide the information related to
your selection.
Part 4. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature

Item Numbers 1.a. - 6.b. Select the appropriate box to indicate whether you read this application yourself or whether
you had an interpreter assist you. If someone assisted you in completing the application, select the box indicating that you
used a preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile
telephone number (if any), and email address (if any). Every application MUST contain the signature of the applicant (or
parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.
Part 5. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1.a. - 7.b. If you used anyone as an interpreter to read the Instructions and questions on this application to
you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and
address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone
number (if any), and his or her email address (if any). The interpreter must sign and date the application.
Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than
the Applicant
Item Numbers 1.a. - 8.b. This section must contain the signature of the person who completed your application, if other
than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete
both Part 5. and Part 6. If the person who completed this application is associated with a business or organization,
that person should complete the business or organization name and address information. Anyone who helped you
complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature
is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he
or she may be obliged to also submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, along with your application.
Part 7. Additional Information
Item Numbers 1.a. - 7.d. If you need extra space to provide any additional information within this application, use the
space provided in Part 7. Additional Information. If you need more space than what is provided in Part 7., you may
make copies of Part 7. to complete and file with your 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.
We recommend that you print or save a copy of your completed application to review in the
future and for your records.

Form I-765V Instructions xx/xx/xx

Page 6 of 10

Required Documentation
You must submit all evidence requested in these Instructions with your application. If you fail to submit required
evidence, USCIS may reject or deny your application for failure to submit requested evidence or supporting documents in
accordance with 8 CFR 103.2(b)(1) and these Instructions.
You may file your application with any credible relevant evidence of your eligibility. USCIS will determine in its
discretion what evidence is credible and the weight to be given that evidence. You are encouraged to provide the
following documentation along with your completed Form I-765V and passport photos.
1. Evidence of your qualifying nonimmigrant status, which may include:

Draft
Not for
Reproduction
01/18/2017

A. Form I-94 front and back (if available).

B. Passport biographic page or Travel Document biographic page and the page with the CBP admission stamp from
the most recent entry into the United States (if available).
C. A copy of any immigration document you may have that was issued by USCIS or legacy Immigration and
Naturalization Service (INS) demonstrating that you were admitted under INA section 101(a)(15) subparagraph
(A), (E)(iii), (G), or (H) (if available).
2. A copy of any documentation you have establishing your identity and current nationality (examples include the photo
page of your passport, NATO agreement, or other immigration documents).
3. Evidence of your spouse’s qualifying nonimmigrant status.

NOTE: Although you may not be able to provide documentary evidence of your spouse’s nonimmigrant status, you
must provide some identifying evidence such as name, place of birth, country of birth, date of birth, date of entry into
the United States, I-94 number, employer, etc. USCIS will conduct a search of the appropriate electronic systems to
attempt to verify the qualifying nonimmigrant status of the spouse.
4. Evidence of your qualifying relationship to your spouse. Evidence may include a marriage certificate, your affidavit,
affidavits from others with knowledge of your qualifying relationship, or other evidence of your legal relationship to
the abuser.
5. Evidence of the abuse, such as protection orders, police reports, court records, medical records, reports from social
services agencies, a signed statement from you detailing abuse suffered since your admission to the United States,
and/or affidavits from third parties who can knowledgeably attest to the abuse you experienced.
6. Photographs. You must submit two identical color passport-style photographs of yourself taken within 30 days of
filing this application. The photos must have a white to off-white background, be printed on thin paper with a glossy
finish, and be unmounted and unretouched.
The two identical color passport-style photos must be 2 by 2 inches. The photos must be in color with full face,
frontal view on a white to off-white background. Head height should measure 1 to 1 3/8 inches from top of hair to
bottom of chin, and eye height is between 1 1/8 to 1 3/8 inches from bottom of photo. Your head must be bare unless
you are wearing headwear as required by a religious denomination of which you are a member. Using a pencil or felt
pen, lightly print your name and A-Number (if any) on the back of the photo.
NOTE: USCIS will apply the “any credible evidence” provision of INA section 204(a)(1)(J) to all applications for
employment under INA section 106. USCIS will consider all credible evidence relevant to the application.
The denial of Form I-765V cannot be appealed. Denial of Form I-765V does not preclude the filing of another application
for employment authorization under INA section 106.
Renewal Applications for Employment Authorization
USCIS may approve a request for renewal of employment authorization under INA section 106. The application for
renewal of employment authorization under INA section 106 must include:
1. A completed and signed Form I-765V;
Form I-765V Instructions xx/xx/xx

Page 7 of 10

2. Two passport-style color photographs;
3. Evidence of the applicant’s current residence in the United States;
4. Evidence the principal nonimmigrant maintains valid immigration status under INA section 101(a)(15)(A), (E)(iii),
(G), or (H) on the date of filing the employment authorization renewal application; and
5. Evidence of previous employment authorizations issued under INA section 106.
An application for EAD renewal may also be filed within two years of the date of the principal nonimmigrant’s death,
within two years of the principal nonimmigrant’s loss of status as a result of an incident of domestic violence, or within
two years of the termination of the marriage if there is a connection between the termination of the marriage and the
battery or extreme cruelty by the principal nonimmigrant spouse.

Draft
Not for
Reproduction
01/18/2017

If you remarry prior to adjudication of Form I-765V, you will be ineligible to renew employment authorization under INA
section 106.
You do not need to resubmit evidence of battery or extreme cruelty, or admission to the United States in qualifying
nonimmigrant status, with your renewal application for employment authorization under INA section 106.
NOTE: If you are unable to provide evidence that the principal nonimmigrant maintains valid immigration status under
INA section 101(a)(15)(A), (E)(iii), (G), or (H), USCIS will conduct a search of the appropriate electronic systems to
attempt to verify the principal nonimmigrant’s status.
NOTE: If you cannot provide copies of the documentation requested above in Renewal Applications for Employment
Authorization, Items 2. - 5., you must submit a signed statement explaining why you cannot provide the documentation.

What Is the Filing Fee?

There are no filing fees or biometric services fees for Form I-765V.
How To Check If the Fees Are Correct

Form I-765V’s filing fee is current as of the edition date in the lower left corner of this page. However, because USCIS
fees change periodically, you can verify that the fees are correct by following one of the steps below.
1. Visit the USCIS website at www.uscis.gov, select “FORMS,” and check the appropriate fee; or

2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for fee information. For TTY (deaf or
hard of hearing) call: 1-800-767-1833.

Where To File?
Please see our website at www.uscis.gov/i-765v or call our National Customer Service Center at 1-800-375-5283 for the
most current information about where to file this application. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Address Change
An applicant who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his
or her previous residence. For information on filing a change of address, go to the USCIS website at www.uscis.gov/
addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of
hearing) call: 1-800-767-1833.
NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not
process change of address requests.
Form I-765V Instructions xx/xx/xx

Page 8 of 10

Processing Information
You must have a United States address to file this application.
Initial Processing. Once USCIS accepts your application we will check it for completeness. If you do not completely fill
out this application, you will not establish a basis for your eligibility and USCIS may reject or deny your application.
Requests for More Information. We may request that you provide more information or evidence to support your
application. We may also request that you provide the originals of any copies you submit. If USCIS requests an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.

Draft
Not for
Reproduction
01/18/2017

Requests for Interview. We may request that you appear at a USCIS office for an interview based on your application.
At the time of any interview or other appearance at a USCIS office, we may require that you provide your fingerprints,
photograph, and/or signature to verify your identity and/or update background and security checks.
Decision. The decision on Form I-765V involves a determination of whether you have established eligibility for the
immigration benefit you are seeking. USCIS will notify you of the decision in writing.
Approval. If your application is approved, we will either mail your EAD to your safe mailing address or we may require
you to visit your local USCIS office to pick it up.
Denial. If USCIS cannot grant your application, you will receive a written notice explaining the basis of your denial.

USCIS Forms and Information

To ensure you are using the latest version of this application, visit the USCIS website at www.uscis.gov where you can
obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order
USCIS forms by calling the Forms Request Line at 1-800-870-3676. You may also obtain forms and information by
calling the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call:
1-800-767-1833.
Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at
www.uscis.gov. Select “Schedule an Appointment” and follow the screen prompts to set up your appointment. Once you
finish scheduling an appointment, the system will generate an appointment notice for you.

Penalties
If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-765V, we
will deny your Form I-765V and may deny any other immigration benefit. In addition, you will face severe penalties
provided by law and may be subject to criminal prosecution.

USCIS Privacy Act Statement
AUTHORITIES: The information requested on this application, and the associated evidence, is collected under INA
section 106 and VAWA 2005 section 814(c), which extends employment authorization eligibility to battered spouses of
nonimmigrants admitted under INA section 101(a)(15) subparagraph (A), (E)(iii), (G), or (H).
PURPOSE: The primary purpose for providing the requested information on this application is to determine your
employment eligibility. The information is used to approve or deny your request for an Employment Authorization
Document.
Form I-765V Instructions xx/xx/xx

Page 9 of 10

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 in the application is confidential and protected from disclosure under
8 USC 1367. The information will be used by and disclosed to DHS personnel and contractors or other agents in
accordance with approved routine uses, as described in the associated published system of records notices [DHSUSCIS-001 - Alien File, Index, and National File Tracking System of Records and DHS-USCIS-007 – Benefit
Information System] which you can find at www.dhs.gov/privacy. DHS may also make the information available, as
appropriate, for law enforcement purposes or in the interest of national security.

Draft
Not for
Reproduction
01/18/2017

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection
of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public
reporting burden for this collection of information is estimated at 3 hours per response, including the time for reviewing
instructions, gathering the required documentation and information, completing the application, preparing statements,
attaching necessary documentation, and submitting the application. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship
and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW,
Washington, DC 20529-2140; OMB No. 1615-XXXX. Do not mail your completed Form I-765V to this address.

Complete this Checklist Before Mailing Form I-765V

Unless stated otherwise, provide photocopies of original documents.

Form I-765V properly signed by you. An original signature or reproduction of an original signature is required.
Two passport-style color photographs

Evidence of your qualifying nonimmigrant status as a spouse who accompanied or followed-to-join a principal
nonimmigrant admitted under INA section 101(a)(15) subparagraph (A), (E)(iii), (G), or (H).
Evidence of your spouse’s nonimmigrant status (if available).

Copies of your marriage certificate or other supporting documentation you may have to demonstrate that you have a
qualifying spousal relationship to your spouse.
For initial applicants for employment authorization, evidence that you or your children were subjected to battery
and/or extreme cruelty by your nonimmigrant spouse.

Form I-765V Instructions xx/xx/xx

Page 10 of 10