Form I-765WS Form I-765 Worksheet

Form I-765 Worksheet

USCIS
Form I-765WS

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

OMB No. 1615-0040
Expires 05/31/2020

If you are applying for employment authorization under the (c)(14), Deferred Action, or (c)(33), Consideration of Deferred Action for
Childhood Arrivals, categories, you must complete this worksheet so we can determine whether you have an economic need to work.
In the spaces provided, indicate your current annual income, your current annual expenses, and the total current value of your assets.
You do not have to submit supporting evidence, but U.S. Citizenship and Immigration Services (USCIS) will accept and review any
documentation that you submit. You do not need to include other household members' financial information to establish your own
economic necessity.

DRAFT
NOT FOR
PRODUCTION
03/30/2020

Part 1. Your Full Name
1.

Given Name (First Name)

Family Name (Last Name)

Middle Name

Part 2. Financial Information
1.

My current annual income is:

$

2.

My current annual expenses are:

$

3.

The total current value of my assets is:

$

Part 3. Explanation

If you would like to provide an explanation regarding your current financial information or your economic need for employment
authorization, use the space below.

Form I-765WS 12/26/19

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