Form I-765V TOC

TABLE OF CHANGES – FORM

Form I-765V, Application for Employment Authorization for Abused Nonimmigrant Spouse

OMB Number: 1615-0137

11/14/2017

Reason for Revision: Comprehensive revision.

Legend for Proposed Text:

• Black font = Current text

• Purple font = Standard language

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 1, For USCIS Use Only	[Page 1] For USCIS Use Only A- EAD Code Assigned: (c) Fee Stamp Action Block Initial Receipt Completed Approved Resubmitted Denied Returned Relocated Received Seat Remarks Application Approved Authorization/Extension Valid From Authorization/Extension Valid To Application Denied	[Page 1] For USCIS Use Only [delete] Fee Stamp Action Block [delete] … Authorization/Extension Valid From Authorization/Extension Valid Through [delete] Remarks
Page 1, To be completed by an Attorney or Accredited Representative (if any)	[Page 1] To be completed by an Attorney or Accredited Representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)	[Page 1] To be completed by an Attorney or Accredited Representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
New		[Page 1] START HERE- Type or print in black ink. Part 1. Reason for Applying I am applying for: 1.a. Initial permission to accept employment. 1.b. Replacement of lost, stolen, or damaged employment authorization document, or correction of my employment authorization document NOT DUE to U.S. Citizenship and Immigration Services (USCIS) error. NOTE: Replacement (correction) of an employment authorization document due to USCIS error does not require a new Form I-765V. Refer to the Form I-765V Instructions for further details. 1.c. Renewal of my permission to accept employment. (Attach a copy of your previous employment authorization document.)
Page 1, Part 1. Information About You	[Page 1] START HERE- Type or print in black ink. Part 1. Information About You 1. 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) 3. USCIS Online Account Number (if any) 4. U.S. Social Security Number (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 Other Names Used (if any) 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. 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 7.b. Street Number and Name 7.c. [ ] Apt. [ ] Ste. [ ] Flr. [fillable field] 7.d. City or Town 7.e. State 7.f. ZIP Code 8. Is your current U.S. physical address the same as your safe mailing address? Y/N If you answered “No” to Item Number 8., provide your U.S. physical address in Item Numbers 9.a.-9.e. [Page 2] U.S. Physical Address 9.a. Street Number and Name 9.b. [ ] Apt. [ ] Ste. [ ] Flr. [fillable field] 9.c. City or Town 9.d. State 9.e. ZIP Code Other Information 13. Country of Citizenship or Nationality 12.a. City or Town of Birth 12.b. State or Province of Birth 12.c. Country of Birth 11. Date of Birth (mm/dd/yyyy) 10. Sex Male Female 14. Have you EVER applied for employment authorization from USCIS? Y/N If you answered “Yes” to Item Number 14., provide the information requested in Item Numbers 15.a.-15.b. for your most recent applications. 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) 19.b. Date Current Status Expired or Will Expire, as shown on Form I-94 (mm/dd/yyyy) 19.c. Passport Number 19.d. Travel Document Number 19.e. Country of Issuance for Passport or Travel Document 19.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 20. 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)).	[Page 1] [delete] Part 2. Information About You [moved to new Part 1] Your Full Name NOTE: USCIS will issue your card in this name. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names Used (if any) 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 9. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.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. 3.a. In Care Of Name 3.b. Street Number and Name 3.c. [ ] Apt. [ ] Ste. [ ] Flr. [fillable field] 3.d. City or Town 3.e. State 3.f. ZIP Code 4. Is your current U.S. physical address the same as your safe mailing address? Yes No If you answered “No” to Item Number 4., provide your U.S. physical address in Item Numbers 5.a.-5.e. [Page 2] U.S. Physical Address 5.a. Street Number and Name 5.b. [ ] Apt. [ ] Ste. [ ] Flr. [fillable field] 5.c. City or Town 5.d. State 5.e. ZIP Code Other Information 6. Alien Registration Number (A-Number) (if any) 7. USCIS Online Account Number (if any) 8.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? Yes No NOTE: If you answered “No” to Item Number 8.a., skip to Item Number 9. If you answered “Yes” to Item Number 8.a., provide the information requested in Item Number 8.b. 8.b. Provide your Social Security number (SSN) (if any) 9. Do you want the SSA to issue you a Social Security card? (You must also answer “Yes” to Item Number 10., Consent for Disclosure, to receive a card.) Yes No NOTE: If you answered “No” to Item Number 9., skip to Item Number 13. If you answered “Yes” to Item Number 9., you must also answer “Yes” to Item Number 10. 10. Consent for Disclosure: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security card. Yes No NOTE: If you answered “Yes” to Item Numbers 9. - 10., provide the information requested in Item Numbers 11.a. - 12.b. Father’s Name Provide your father’s birth name. 11.a. Family Name (Last Name) 11.b. Given Name (First Name) Mother’s Name Provide your mother’s birth name. 12.a. Family Name (Last Name) 12.b. Given Name (First Name) Your Country or Countries of Citizenship or Nationality List all countries where you are currently a citizen or national. If you need extra space to complete this item, use the space provided in Part 9. Additional Information. 13.a. Country 13.b. Country Place of Birth 14.a. City/Town/Village of Birth 14.b. State/Province of Birth 14.c. Country of Birth 15. Date of Birth (mm/dd/yyyy) 16. Gender Male Female Information About Your Most Recently Filed Employment Authorization 17. Have you previously applied for employment authorization or for an Employment Authorization Document (EAD)? Yes (Complete Item Numbers 18.a. - 18.d.) No (Proceed to Item Number 19.) [Delete] 18.a. Receipt Number of Your Most Recently Filed Application for Employment Authorization 18.b. Which USCIS office adjudicated this application? 18.c. Enter the date USCIS approved or denied this application (mm/dd/yyyy) [Page 3] 18.d. Was this application approved or denied? Approved Denied NOTE: Attach all documentation from your previous employment authorization (for example, a copy of your previous EAD, approval notice, or denial notice). Information About Your Last Arrival in the United States 19. Place of Your Last Admission Into the United States 20. Date of Your Last Admission Into the United States, On or About (mm/dd/yyyy) 21. Your Immigration Status When You Were Last Admitted Into the United States (for example, A-2, E-3, G-1, H-4) 22.a. Form I-94 Arrival-Departure Record Number (if any) 22.b. Date Your Current Status Expired or Will Expire, As Shown On Form I-94 (mm/dd/yyyy) 22.c. Passport Number 22.d. Travel Document Number 22.e. Country That Issued Your Passport or Travel Document 22.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 23. Your Current Immigration Status (for example, A-2, E-3, G-1, H-4, deferred action, no lawful status) 24. 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 you. In the space below, enter the letter and number for your eligibility category. (For example, (c)(27), (c)(28), (c)(29), (c)(30).)
New		[page 3] Part 3. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2. Race (Select all applicable boxes) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 3. Height  Feet/Inches 4. Weight    Pounds 5. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Page 2, Part 2. Information About Your Spouse	[Page 2] Part 2. Information About Your Spouse Provide the following information, if known. 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. [fillable field] 4.c. City or Town 4.d. State 4.e. ZIP Code Other Information 5. A-Number (if any) 6. USCIS Online Account Number (if any) 7.a. Form I-94 Arrival-Departure Record Number (if any) 7.b. Passport Number 7.c. Travel Document Number 7.d. Country of Issuance for Passport or Travel Document 7.e. Expiration Date for Passport or Travel Document Number (mm/dd/yyyy) 8. 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. Additional Information.)	[Page 3] Part 4. Information About Your Spouse For all of the questions in Part 4., provide the following information, if known. 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. [fillable field] 4.c. City or Town 4.d. State 4.e. ZIP Code [page 4] Other Information 5. Alien Registration Number (A-Number) (if any) 6. USCIS Online Account Number (if any) 7.a. Form I-94 Arrival-Departure Record Number (if any) 7.b. Passport Number 7.c. Travel Document Number 7.d. Country That Issued Your Spouse’s Passport or Travel Document 7.e. Expiration Date for Passport or Travel Document Number (mm/dd/yyyy) 8. 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 9. Additional Information.)
Page 3, Part 3. Marriage Information	[Page 3] Part 3. Marriage Information Your Current Marital Status (Select only one box) 1.a. Married 1.b. Date of Marriage (mm/dd/yyyy) 1.c. City or Town of Marriage 1.d. Country of Marriage 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 5.b. Date of Annulment (mm/dd/yyyy)	[Page 4] Part 5. Marriage Information Your Current Marital Status (Select only one box.) 1.a. Married 1.b. Date of Marriage (mm/dd/yyyy) 1.c. City or Town of Marriage 1.d. Country of Marriage 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 5.b. Date of Annulment (mm/dd/yyyy)
Pages 3-4., Part 4. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature	[Page 3] Part 4. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature 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. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 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 [Fillable Field], a language in which I am fluent, and I understood everything. 2. [] At my request, the preparer named in Part 6., [Fillable Filed], prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Applicant’s Declaration and Certification 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 information from any and all 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. [Page 4] 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 6.a. Applicant’s Signature 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.	[Page 4] Part 6. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-765V Instructions before completing this section. You must file Form I-765V while in the United States. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 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 7. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 8., [Fillable Filed], prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) [page 5] Applicant’s Declaration and Certification 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 information from any and all 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. I understand that USCIS will require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. 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 6.a. Applicant’s Signature (sign in ink) 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.
Page 4, Part 5. Interpreter’s Contact Information, Certification, and Signature	[Page 4] 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) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. [ ] Apt. [ ] Ste. [ ] Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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 I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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 (sign in ink) 7.b. Date of Signature (mm/dd/yyyy)	[Page 5] Part 7. 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) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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) [page 6] Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 6., 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 (sign in ink) 7.b. Date of Signature (mm/dd/yyyy)
Pages 4-5, Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 4] 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 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) [Page 5] Preparer’s Mailing Address 3.a. Street Number and Name 3.b. [ ] Apt. [ ] Ste. [ ] Flr. [fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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 [] extends [] does not extend beyond the 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. 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 8.a. Preparer’s Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)	[Page 6] Part 8. 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 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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) [Page 6] 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 extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. 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 Declaration and 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 8.a. Preparer’s Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
Page 6, Part 7. Additional Information	[Page 6] 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) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Numb er 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]	[Page 7] Part 9. 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) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

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