Page 1
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[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)
START HERE - Type or print in
black ink.
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[Page 1]
To be completed by an Attorney or
Accredited Representative.
Select this box if Form G-28 is
attached.
Attorney State Bar Number
Attorney or Accredited
Representative USCIS Online Account Number
START HERE - Type or print in black ink.
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.
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Page 1-3,
Part 2. Information
About You
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[Page 1]
Part 2. Information About You
1. Your Full Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2. Other Names Used
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 6. Additional Information.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
[Page 2]
3. Your U.S. Mailing Address
or Safe Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
4. Is this a safe mailing
address?
Yes
No
5. Is your current mailing
address or safe mailing address the same as your physical address?
Yes
No
NOTE: If you answered “No”
to Item Number 5., provide your physical address below.
6. U.S. Physical Address
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Other Information
7. Alien Registration Number
(A-Number) (if any)
8. USCIS Online Account
Number (if any)
9. Gender
Male
Female
10. Marital Status
Single
Married
Divorced
Widowed
11. Place of Birth
List the city/town/village,
state/province, and country where you were born.
A. City/Town/Village of Birth
B. State/Province of Birth
C. Country of Birth
12. Date of Birth
(mm/dd/yyyy)
13. 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 6.
Additional Information.
A. Country
B. Country
14. Have you previously filed
Form I-765?
Yes
No
[Page 3]
Information About Your Last
Arrival in the United States
15.A. Form I-94
Arrival-Departure Record Number (if any)
B. Passport Number of Your
Most Recently Issued Passport
C. Travel Document Number (if
any)
D. Country That Issued Your
Passport or Travel Document
E. Expiration Date for
Passport or Travel Document (mm/dd/yyyy)
16. Date of Your Last Arrival
Into the United States, On or About (mm/dd/yyyy)
17. Place of Your Last
Arrival Into the United States
18. Immigration Status at
Your Last Arrival (for example, B-2 visitor, F-1 student, or no
status)
19. Your Current Immigration
Status or Category (for example, F-1 student, parolee, deferred
action, or no status or category)
20. Student and Exchange
Visitor Information System (SEVIS) Number (if any)
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[Page 1]
Part 2. Information About You
1. Your
Full Legal Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
2. Other
Names Used
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 6. Additional Information.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
[Page 2]
3. Your
U.S. Mailing Address or Safe Mailing Address
In Care Of
Name
Street Number
and Name
Apt./Ste./Flr.
[Number]
City or Town
State
ZIP Code
4. Is this a safe mailing
address?
Yes
No
5. Is your current mailing
address or safe mailing address the same as your physical address?
Yes
No
NOTE: If
you answered “No” to Item Number 5., provide
your physical address below.
6. U.S.
Physical Address
Street Number
and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Other
Information
7. Alien
Registration Number (A-Number)
8. USCIS
Online Account Number
9. Gender
Male
Female
10.
Marital Status
Single
Married
Divorced
Widowed
11. Place
of Birth
List the
city/town/village, state/province, and country where you were
born.
A.
City/Town/Village of Birth
B.
State/Province of Birth
C. Country
of Birth
12. Date
of Birth (mm/dd/yyyy)
13. 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 6.
Additional Information.
A. Country
B. Country
14. Have you previously filed
Form I-765?
Yes
No
[Page 3]
Information About Your Last
Arrival in the United States
15.A. Form I-94
Arrival-Departure Record Number
B. Passport Number of Your
Most Recently Issued Passport
C. Travel Document Number
D. Country That Issued Your
Passport or Travel Document
E. Expiration Date for
Passport or Travel Document (mm/dd/yyyy)
16. Date of Your Last Arrival
Into the United States, On or About (mm/dd/yyyy)
17. Place of Your Last
Arrival Into the United States
18. Immigration Status at
Your Last Arrival (for example, B-2 visitor, F-1 student, or no
status)
19. Your Current Immigration
Status or Category (for example, F-1 student, parolee, deferred
action, or no status or category)
20. Student and Exchange
Visitor Information System (SEVIS) Number
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Page 3-4,
Part 3. Information
About Your Eligibility Category
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[Page 3]
Part 3. Information About Your
Eligibility Category
1. Eligibility Category. Refer
to the Who May File Form I-765 section of the Form I-765
Instructions to determine the appropriate eligibility category for
this application. Enter the appropriate letter and number for your
eligibility category below (for example, (a)(8), (c)(17)(iii)).
[Three fillable fields separated by
parenthesis]
2. (c)(3)(C) STEM OPT
Eligibility Category. If you entered the eligibility category
(c)(3)(C) in Item Number
1., provide the information
requested in Items A. - C.
A. Degree
B. Employer's Name as Listed
in E-Verify
C. Employer's E-Verify
Company Identification Number or a Valid E-Verify Client Company
Identification Number
3.A. (c)(8) Eligibility Category.
If you entered the (c)(8) eligibility category in Item
Number 1., are you eligible for benefits under the ABC
settlement agreement as a Salvadoran or Guatemalan national?
Yes
No
B. If you entered the
eligibility category (c)(8) in Item Number 1., have you
EVER been arrested for and/pr convicted of any crime?
Yes
No
NOTE: If you answered “Yes”
to Item B. in Item Number 3., refer to Special
Filing Instructions for Those With Pending Asylum Applications
(c)(8) in the Required Documentation section of the
Form I-765 Instructions for information about providing court
dispositions.
4. (c)(26) Eligibility Category.
If you entered the eligibility category (c)(26) in Item
Number 1., provide the receipt number of your H-1B spouse’s
most recent Form I-797 Notice for Form I-129, Petition for a
Nonimmigrant Worker.
[Page 4]
5.A. (c)(35) and (c)(36)
Eligibility Category. If you entered the eligibility category
(c)(35) in Item Number 1., please provide the receipt
number of your Form I-797 Notice for Form I-140, Immigrant
Petition for Alien Worker. If you entered the eligibility category
(c)(36) in Item Number 1., please provide the receipt
number of your spouse's or parent's Form I-797 Notice for Form
I-140.
B. If you entered the
eligibility category (c)(35) or (c)(36) in Item Number
1., have you EVER been arrested for and/or convicted of
any crime?
Yes
No
NOTE: If you answered “Yes”
to Item B. in Item Number 5., refer to
Employment-Based Nonimmigrant Categories, Items 8. - 9.,
in the Who May File Form I-765 section of the Form I-765
Instructions for information about providing court dispositions.
[new]
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[Page 3]
[no change]
6.
If you entered the eligibility
category (c)(9) in Item Number 1.,
and are applying under one of following immigrant categories,
select the applicable box. Select only one box.
I
am the principal applicant adjusting status based on my dependent
status under the Haitian Refugee Immigrant Fairness Act for
battered spouses and children.
I
am the principal applicant adjusting status under the Nicaraguan
Adjustment and Central American Relief Act for battered spouses
and children.
I
am a Special Immigrant based on an approved Form I-360 as an
Afghan or Iraqi Translator or Interpreter, Iraqi National
employed by or on behalf of the U.S. Government, or Afghan
National employed by or on behalf of the U.S. government or
employed by the International Security Assistance Forces.
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Page 8,
Part 8. Additional
Information
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[Page 8]
Part 8. 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. Family Name (Last Name)
Given Name (First Name)
Middle Name
2. A-Number (if any)
3.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
4.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
5.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
6.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
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[Page 8]
Part 8. 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 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. Family Name (Last Name)
Given Name (First Name)
Middle Name
2. A-Number
3.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
4.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
5.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
6.
A. Page Number
B.
Part Number
C.
Item Number
D.
[Fillable field]
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