Pta

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]

Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:

I-765 and I-765WS

Form Title:
Component:

Application for Employment Authorization and Worksheet
U.S. Citizenship and
Office:
Service Center
Immigration Services
Operations
(USCIS)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title: From I-765, Application for Employment Authorization and
Form I-765WS, Worksheet
OMB Control
1615-0040
OMB Expiration
February 28, 2018
Number:
Date:
Collection status: Revision
Date of last PTA (if August 21, 2013
applicable):
Name:
Office:
Phone:
Name:

PROJECT OR PROGRAM MANAGER
Michelle L. Young
Service Center Operations
Title:
Adjudication Officer (Policy)
802-527-3012
Email:
[email protected].
gov

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Kerstin A. Jager

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Office:

Phone:

Office of Policy and
Title:
Adjudication Officer
Strategy
202 213 4211
Email:
[email protected]
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
2017 Update
Form I-765 and I-765WS are set to expire on February 28, 2018 and USCIS is revising the
currently approved information collection as part of the Paperwork Reduction Act (PRA).
USCIS is submitting this updated Form I-765 PTA to document the following revisions:
• As part of the joint effort between DoS, USCIS, and SSA, USCIS will obtain consent for
the transmission of his or her enumeration data to SSA on the Form I-765.
• The USCIS Online Account Number for a previously filed an application, petition,
or request using the USCIS online filing system (previously called USCIS Electronic
Immigration System (USCIS ELIS))
• The Student and Exchange Visitor Information System (SEVIS) Number was
added in order to validate a student applicant’s information in SEVIS.
• Captures additional biometric information including ethnicity, race, height,
weight, eye color, and hair color to facilitate processing of initial and renewal
requestors at an ASC.
• Other new information collections include: physical address (if different from the
mailing address and other information about the applicant’s not recently filed I765, information about applicant’s Last Arrival in the United States, and arrest for
convictions of any crime.

USCIS is making no updates to the Form I-765WS, Worksheet.

Form I-765, Application for Employment Authorization
Individuals who are temporarily in the United States and eligible for employment
authorization may file a Form I-765, Application for Employment Authorization, to
request an Employment Authorization Document (EAD). Other individuals who are

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

authorized to work in the United States without restrictions should also use this form to
apply for a document evidencing such authorization.

I-765 Worksheet (WS)
An EAD based on a grant of deferred action requires a showing of economic necessity.
To facilitate this economic necessity review, a separate worksheet (Form I-765WS) was
created. There is a general presumption that Deferred Action for Childhood Arrivals
(DACA) requestors will need to work given their undocumented circumstances and the
fact that they are not generally anticipated to have independent means. Absent evidence
of sufficient independent financial resources, the Form I-765WS is sufficient to establish
economic need without any further economic analysis. Additionally, the agency decided
that all deferred action I-765 applicants must complete the I-765WS after it was
determined to create the I-765WS for DACA. The agency has added a certification
section to the Form I-765WS so that individuals can sign the form.
Relevant IT Systems
USCIS uses the following systems to process Form I-765.
• Computer Linked Adjudication Information Management System (CLAIMS
3): For the majority of the populations of individuals who can file Form I-765, it
will be processed in CLAIMS 3.
• USCIS Electronic Immigration System (USCIS ELIS): Some populations of
individuals who file Form I-765, it will be processed using USCIS ELIS.

The completed paper and electronic form will be stored in the applicant’s receipt file or
Alien File.

b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
8 CFR 274.a.13; 8 U.S.C. section 1324a.
2. Describe the IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

c. Who will complete and
submit this form? (Check
all that apply.)

d. How do individuals
complete the form? Check
all that apply.

☒ Yes
☐ No

☒ Members of the public
☐ U.S. citizens or lawful permanent
residents
☐ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

☒ The record subject of the form (e.g., the
individual applicant).
☒ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.
If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.
☐ DHS employee or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

1
Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
Form I-765, Application for Employment Authorization collects information from the
applicant and preparer.
Information about applicant includes:
•
•
•
•
•
•
•
•
•
•
•
•
•

First Name

Middle Name
Last Name

Addresses (Physical and Mailing)

Telephone Number(s)
E-mail address
Alias(es)

Country of Citizenship/Nationality
Place and date of Birth
Sex

Marital Status

Social Security Number, if any

SSA EBE questions:
•

•
•
•

•
•
•
•
•
•
•

Do you want SSA to issue you a Social Security card? (Yes/No)

SSA Consent for Disclosure (Yes/No)

Father’s Name (Family Name, Given Name)

Mother’s Name (Family Name, Given Name)

USCIS Online Account Number
Alien Number
I-94 Number

Passport Number

Travel Document Number

Country of Issuance for Passport or Travel Document
Expiration Date for Passport or Travel Document.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Date of Last Arrival into the United States

Place of Last Arrival into the United States
Status of Last Arrival

Current Immigration Status
Signature
Ethnicity
Race

Height

Weight

Eye Color

Hair Color

Student Exchange Visitor Information System (SEVIS) Number (if any)

Receipt Number for most recent Application for Employment Authorization
USCIS Office where last EAD Application was adjudicated
Date EAD Application was adjudicated
Eligibility Category
• Degree

• Employer’s Name as listed in E-Verify

• Employee’s E-Verify Company ID or Client ID

• Physical Address of Employers (street name, number, city/town, state,
zipcode)

Preparer/Interpreter information includes:
•
•
•
•
•
•

Full Name

Organization

Physical, Mailing, and Email Addresses
Phone and Fax Numbers

Relationship to the requestor
Signature

Preparer (including Accredited Representative and Attorney) information includes:

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

•
•
•
•
•
•
•

Full Name

Organization

USCIS Online Account Number

Physical, Mailing, and Email Addresses
Phone and Fax Numbers

Relationship to the requestor (preparer only)
Signature

Form I-765 Worksheet collects the following information:
•
•
•
•
•
•
•
•
•

First name

Middle Name
Last Name

Current Annual Income

Current Annual Expenses
Current Value of Assess
Additional Information
Signature

Telephone Number

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.

☒ Social Security number
☒ Alien Number (A-Number)
☐ Tax Identification Number
☐ Visa Number
☒ Passport Number
☐ Bank Account, Credit Card, or other
financial account number
☒ Other. Please list: USCIS Online
Account Number and SEVIS Number

☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☐ Social Media Handle/ID
☐ Known Traveler Number
☐ Trusted Traveler Number (Global
Entry, Pre-Check, etc.)
☐ Driver’s License Number
☐ Biometrics

g. List the specific authority to collect SSN or these other SPII elements.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

INA 264(f) (8 U.S.C. 1304(f)), states, “Alien's social security account number
Notwithstanding any other provision of law, the Attorney General is authorized to
require any alien to provide the alien's social security account number for purposes of
inclusion in any record of the alien maintained by the Attorney General or the Service.”
h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
USCIS collects the applicant’s social security number on Form I-765, Application for an
Employment Authorization Document, in accordance with the Paperwork Reduction Act
and the Immigration and Nationality Act. The collection of the applicant’s Social Security
Number (SSN) is very important in the context of an Application for Employment
Authorization Document (EAD) for a number of reasons. First, the EAD evidences that an
individual is authorized for employment, and in the United States the SSN is the primary
number associated with employment records, tax collection, and lawful employment.
The USCIS E-Verify program uses the SSN to interface immigration records and Social
Security Administration databases. Without SSNs, we lose the integrity of this interface.
The SSN provided on the application for an EAD can be used to determine whether an
applicant has worked previously in the U.S. and if that employment was lawful.
i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of
the collection or is
form filled out by
third party)?

☒ Yes. Please describe how notice is provided.
Per Privacy Act Statement on the form instructions
☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
Individuals may complete a PDF and submit a
completed IC/forms?
paper application to USCIS. The completed form
will be stored in a receipt file or an A-file.
☒ Electronic. Please describe the IT system that will
store the data from the form.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Computer Linked Adjudication Information
Management System (CLAIMS 3): For the majority
of the populations of individuals who can
complete this application, the completed Form I765 will be entered into CLAIMS 3.
USCIS Electronic Immigration System (USCIS
ELIS), and: Some form I-765 are processed using
USCIS ELIS. The completed Form I-765 will be
entered into USCIS ELIS.

Refugees, Asylum, and Parole System (RAPS):
Asylum applicants and refugees complete the I765 for employment authorization as well. When
an affirmative asylum application is approved by
an asylum office, RAPS initiates the EAD
production so that information is stored in RAPS.
After a person has asylum status and needs an
extension or replacement EAD, they file an I-765,
which entered into CLAIMS 3. Refugees file an I765 for the initial card and any extensions, which
is also in CLAIMS 3.

b. If electronic, how
does DHS input the
responses into the IT
system?

Privacy Threshold Analysis – IC/Form

☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Form I-765 may also be scanned using the
Enterprise Document Management System (EDMS).
☒ Manually (data elements manually entered). Please
describe.
For those I-765s direct filed at a Service Center,
data entry clerks manually enter data from the
form into CLAIMS3.
☒ Automatically. Please describe.
For those I-765s filed through a Lockbox, the form,
fee and support documents are scanned and the
data is populated using Optical Character Reader
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention
schedule(s)? Include
the records schedule
number.

e. How do you ensure
that records are
disposed of or deleted
in accordance with
the retention
schedule?

technology. The data is then verified and
corrected, if needed, by keying clerks via OnBase
(JPMorgan data collection system). The data
(scanned and keyed) is sent USCIS (scanned is
stored in EDMS, keyed is stored in CLAIMS3 or
ELIS depending on form type).

☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Receipt number, USCIS Online Account Number,
SSN, A number, Name, Date of Birth, or a
combination.

☐ By a non-personal identifier. Please describe.
Click here to enter text.
CLAIMS 3: CLAIMS 3 deletes and destroys records 50
years from the date of the last completed action [DAA-

0566-2016-0009 and DAA-0566-2016-0013 ]

USCIS ELIS/EDMS: Records are retained
permanently. [EDMS: N1-566-08-17]

RAPS/APSS: RAPS [N1-563-04-06] and APSS [N1563-04-07] Retention Schedule. Master File
automated records are maintained for 25 years after
the case is closed, then archived for 75 years
The system owner is responsible for ensuring the
records are deleted in accordance with the records
retention schedule.

2
Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☒ Yes, information is shared with other DHS components or offices. Please describe.
The information from the form may be shared to other ICE and CBP via system
access.
☒ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.

USCIS will share Form I-765 information with SSA to produce a social security number
for the applicant, if consent is provided.
☐ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:
Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

Jenny Hoots

August 29, 2017

September 20, 2017

☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Privacy Office recommendation is to designate Form I-765 a privacy sensitive
form with coverage under DHS/USCIS/PIA-016(a) CLAIMS 3 and Associated Systems PIA,
DHS/USCIS/PIA-027 Refugees, Asylum, and Parole System and the Asylum Pre-Screening
System and respective updates, and DHS/USCIS/PIA-056 USCIS Electronic Immigration
System (USCIS ELIS) the DHS/USCIS/PIA-003 Integrated Digitization Document
Management Program (IDDMP) PIA.
USCIS recommends SORN coverage under the following SORNs:
• DHS/USCIS-010 – Asylum Information and Pre-Screening,
• DHS-USCIS-007 - Benefits Information System
• DHS/USCIS-001 - Alien File, Index, and National File Tracking System of Records

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Kameron Cox

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1150531
September 25, 2017
September 25, 2020

DESIGNATION

Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

DHS IC/Forms Review:

DHS PRIV has approved this ICR/Form.

Determination:

☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

Date IC/Form Approved September 22, 2017
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
e(3) statement update is required.
Statement:
Privacy Act Statement must be converted into a Privacy Notice
PTA:
CLAIMS 3 and ELIS PTAs are adequate
PIA:
System covered by existing PIA
If covered by existing PIA, please list:
DHS/USCIS/PIA-061 Benefit Request Intake Process

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

DHS/USCIS/PIA-003(b) Integrated Digitization Document Management
Program
DHS/USCIS/PIA-016(a) Computer Linked Application Information
Management System (CLAIMS 3) and Associated Systems
DHS/USCIS/PIA-027(c) USCIS Asylum Division
DHS/USCIS/PIA-056 USCIS Electronic Immigration System
SORN:
System covered by existing SORN
If covered by existing SORN, please list:
DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking
System of Records, September 18, 2017, 82 FR 43556
DHS/USCIS-007 Benefits Information System, October 19, 2016 81 FR
72069
DHS/USCIS-010 Asylum Information and Pre-Screening System of
Records, November 30, 2015, 80 FR 74781
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
USCIS is submitting this updated Form I-765 PTA to document the following revisions: the
transmission of applicant enumeration data to SSA, addition of the USCIS Online Account
Number and the Student and Exchange Visitor Information System Number, and the
capture of additional biometric information and physical address. There are no updates to
the Form I-765WS.

The DHS Privacy Office (PRIV) agrees with USCIS that Form I-765 is a privacy sensitive
information collection requiring PIA coverage because it collects PII from members of the
public. PRIV finds that existing PIAs provide adequate coverage. DHS/USCIS/PIA-061
Benefit Intake PIA assesses the risks of the collection and processing of Forms I-765 and I765WS. DHS/USCIS/PIA-003(b) IDDMP covers the scanning and storage of the forms in
EDMS. DHS/USCIS-016(a) CLAIMS 3 and DHS/USCIS/PIA-056 ELIS cover the storage and
processing of forms I-765 and I765WS data elements in their systems. DHS/USCIS/PIA027(c) Asylum Division assesses the risks for storing the I-765 and I-765WS of asylum
seekers and refugee applicants in RAPS and APSS.
PRIV finds that SORN coverage is required because PII collected by Forms I-765 and I765WS are stored in systems that retrieve information by unique identifier. PRIV
concludes that SORN coverage can be found in existing SORNs. DHS/USCIS/ICE/CBP-001
Alien File covers the collection, use, and maintenance of PII to facilitate administration of
benefits and enforcement of provisions under the INA and related immigration statutes.
DHS/USCIS-007 BIS SORN covers the use of PII in intake, processing, and decisional data

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

that may not interact with the A-file. Finally, DHS/USCIS-010 Asylum SORN covers the
storage of Forms I-765 and I-765WS in RAPS/APSS. PRIV recommends that as all these
SORNs are updated they include attorney USCIS online account number as a data element
in categories of record and retrievability.

This PTA contemplates sharing PII with the Social Security Administration. This sharing is
permitted under Routine Use DD of the A-File SORN and Routine Use S of the BIS SORN.
This sharing is compatible with the purpose of both SORNs because the information is
shared to assist in issuing a social security number to the applicant as part of the
immigration process.
PRIV finds that a Privacy Notice is required because Forms I-765 and I-765WS collect PII
from Non-US persons that is then stored in systems of records. USCIS must update its
Privacy Act Statement to a Privacy Notice.

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