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 06/30/2022

If you are applying for employment authorization under the (c)(14), Deferred Action, (c)(18) Aliens Ordered Removed and Released
from Custody on Orders of Supervision, or (c)(33), Consideration of Deferred Action for Childhood Arrivals, you must complete this
worksheet. U.S. Citizenship and Immigration Services (USCIS) will use the information you provide to determine whether you have
established an economic need to work. In the spaces provided below, 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 USCIS will accept and
review any documentation that you choose to submit. You do not need to include other household members' financial information to
establish your own economic necessity.

DRAFT
NOT FOR
PRODUCTION
08/24/2020

Part 1. Your Full Name
1.

Family Name (Last Name)

Given Name (First 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 Edition 06/30/20

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