I-765V Application for Employment Authorization for Abused Noni

Application for Employment Authorization for
Abused Nonimmigrant Spouse

USCIS
Form I-765V

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-XXXX
Expires XX/XX/XXXX

Action Block

Fee Stamp

For USCIS Use Only

AEAD Code Assigned: (c)
Initial Receipt
Resubmitted

Completed
Approved
Denied
Returned

Application
Approved

Relocated

Remarks

Received
Sent

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Authorization/Extension Valid From

Application Denied

Authorization/Extension Valid To

Select this box if
Form G-28 is
attached.

To be completed by an
Attorney or Accredited
Representative (if any).

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

Other Names Used (if any)

1.

Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 7.
Additional Information.

I am applying for:

Initial permission to accept employment.

Replacement. (Lost, stolen, mutilated card, or my
card contains incorrect information not attributed to
U.S. Citizenship and Immigration Services (USCIS)
error.)
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
authorization document.)
2.

Alien Registration Number (A-Number) (if any)
► A-

3.

USCIS Online Account Number (if any)
►

4.

U.S. Social Security Number (if any)

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

6.c. Middle Name

Safe Mailing Address

NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
mailing address.
7.a. In Care Of Name (if any)

►

Your Full Name
NOTE: USCIS will issue your card in this name.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name

7.b. Street Number
and Name
7.c. Apt.

Ste.

Flr.

7.d. City or Town
7.e. State
8.

7.f.

ZIP Code

Is your current U.S. physical address the same as your
safe mailing address?
Yes
No
If you answered "No" to Item Number 8., provide your
U.S. physical address in Item Numbers 9.a. - 9.e.

Form I-765V xx/xx/xx

Page 1 of 6

19.b. Date Current Status Expired or Will Expire, as shown on
Form I-94 (mm/dd/yyyy)

Part 1. Information About You (continued)
U.S. Physical Address

19.c. Passport Number

9.a. Street Number
and Name
9.b. Apt.

Ste.

19.d. Travel Document Number

Flr.

19.e. Country of Issuance for Passport or Travel Document

9.c. City or Town
19.f. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

9.e. ZIP Code

9.d. State

Other Information

Current Immigration Status (for example, A-2, E-3, G-1,
H-4, No Lawful Status)

21.

Eligibility Category. Refer to the Who May File Form
I-765V section of the Form I-765V Instructions to
determine the appropriate eligibility category for this
application. In the space below, enter the letter and
number for your eligibility category. (For example,
(c)(27), (c)(28), (c)(29), (c)(30)).

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10.

Sex

11.

Date of Birth (mm/dd/yyyy)

Male

20.

Female

12.a. City or Town of Birth

12.b. State or Province of Birth
12.c. Country of Birth
13.
14.

Part 2. Information About Your Spouse

Country of Citizenship or Nationality

Provide the following information, if known.

Have you EVER applied for employment authorization
from USCIS?
Yes
No

If you answered "Yes" to Item Number 14., provide the
information requested in Item Numbers 15.a. - 15.b. for
your most recent application.
15.a. Which USCIS Office?

15.b. What was the result?

Approved

Denied

NOTE: Attach all documentation from your previous
employment authorization.
16.

Place of Last Entry into the United States

17.

Date of Last Entry into United States, on or about
(mm/dd/yyyy)

18.

Immigration Status of Last Entry (for example, A-2, E-3,
G-1, H-4)

19.a. Form I-94 Arrival-Departure Record Number (if any)
►
Form I-765V xx/xx/xx

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

U.S. Physical Address

4.a. Street Number
and Name
4.b. Apt.

Ste.

Flr.

4.c. City or Town
4.d. State

4.e. ZIP Code

Other Information
5.

A-Number (if any)
► A-

Page 2 of 6

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

Part 2. Information About Your Spouse
(continued)
6.

USCIS Online Account Number (if any)
►

7.a. Form I-94 Arrival-Departure Record Number (if any)
►

Applicant's Statement

7.b. Passport Number

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.

7.c. Travel Document Number

1.a.

I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.

1.b.

The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in

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7.d. Country of Issuance for Passport or Travel Document
7.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
8.

NOTE: Read the Penalties section of the Form I-765V
Instructions before completing this part. You must file Form
I-765V while in the United States.

Your Spouse's Nonimmigrant Status (Select only one box)
A-1

A-2

A-3

E-3

G-1

G-2

G-3

G-4

G-5

H-1B

H-1B1

H-1C

H-2A

H-2B

H-2R

H-3

Other (Use the space provided in Part 7.

2.

At my request, the preparer named in Part 6.,

Part 3. Marriage Information

Applicant's Contact Information

Your Current Marital Status (Select only one box)

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Married

1.b. Date of Marriage (mm/dd/yyyy)
1.c. City or Town of Marriage
1.d.

,

prepared this application for me based only upon
information I provided or authorized.

Additional Information)

1.a.

,

a language in which I am fluent, and I understood
everything.

Country of Marriage

Applicant's Declaration and Certification

2.a.

Divorced

2.b. Date of Divorce (mm/dd/yyyy)
3.a.

Widowed

3.b. Date of Spouse's Death
(mm/dd/yyyy)
4.

Separated

5.a.

Marriage Annulled

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any and all information from any of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

5.b. Date of Annulment (mm/dd/yyyy)
Form I-765V xx/xx/xx

Page 3 of 6

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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
correct.

Applicant's Signature

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

Interpreter's Certification

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6.a. Applicant's Signature

I certify, under penalty of perjury, that:

I am fluent in English and

6.b. Date of Signature (mm/dd/yyyy)

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.

Part 5. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.

Interpreter's Business or Organization Name (if any)

,

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.

Interpreter's Signature

7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2.

Preparer's Business or Organization Name

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-765V xx/xx/xx

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Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Province

3.g. Postal Code
3.h. Country

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.

Preparer's Signature

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3.e. ZIP Code

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Preparer's Statement
7.a.

I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and
my representation of the applicant in this case
does not extend beyond the
extends
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.

Form I-765V xx/xx/xx

Page 5 of 6

5.a. Page Number

Part 7. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this 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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.d.

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6.a. Page Number

A-Number (if any)

5.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

► A-

3.a. Page Number
3.d.

3.b. Part Number

3.c. Item Number

6.d.

7.a. Page Number

4.a. Page Number
4.d.

Form I-765V xx/xx/xx

4.b. Part Number

4.c. Item Number

7.d.

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