I-765 Form Table of Changes

TABLE OF CHANGES – FORM

Form I-765, Application For Employment Authorization

OMB Number: 1615-0040

[Date]      

Reason for Revision:

Project Phase:

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Expires 07/31/2022

Edition Date 05/31/2022

Current Page Number and Section	Current Text	Proposed Text
Page 1	[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.	[Page 1] [no change]
Page 1, Part 1. Reason for Applying	[Page 1] Part 1. Reason for Applying 1. I am applying for (select only one box): A. An initial employment authorization document. B. Replacement of: (1) Lost employment authorization document. (2) Stolen employment authorization document. (3) Damaged employment authorization document. (4) Correction of my employment authorization document NOT DUE to U.S. Citizenship and Immigration Services (USCIS) error. NOTE: For more information about replacement or correction of an employment authorization document, including due to USCIS error, refer to Replacement for Card Error in the What Is the Filing Fee section of the Form I-765 Instructions. C. Renewal of my employment authorization document.	[Page 1] [no change]
Page 1-3, Part 2. Information about You	[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 8. 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 8. 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)	[Page 1] [no change]
Page 3-4, Part 3. Information About Your Eligibility Category	[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. (c)(8) Eligibility Category. If you entered the eligibility category (c)(8) in Item Number 1., provide the information requested in Items A. - D. 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. Have you EVER been arrested for, and/or charged with, and/or convicted of any crime in any country? 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. C. Did you enter the United States lawfully through a U.S. port of entry and were you inspected and admitted or paroled after inspection by an immigration officer? (If you answer “Yes,” you MUST provide evidence of your lawful entry.) Yes No [Page 4] D. If you answered “No” to Item C., did you present yourself to the Secretary of Homeland Security or his or her delegate (DHS) within 48 hours of entry or attempted entry AND express an intention to seek asylum within the United States or express a fear of persecution or torture in your home country? Yes No If you answered “Yes” to Item D., provide the following information: Date you presented yourself to DHS Location where you presented yourself to DHS Country of claimed persecution Provide an explanation for why you did not enter the United States lawfully through a U.S. port of entry. If you need extra space to complete this item, use the space provided in Part 8. Additional Information. [fillable field] NOTE: Refer to the Special Filing Instructions for Those With Pending Asylum Applications (c)(8) section of the Form I-765 Instructions for more information. 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. 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.	[Page 3] Part 3. Information About Your Eligibility Category [no change] 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/or convicted of any crime? Yes No [no change] [deleted] [no change]
Page 4-5, Part 4. Social Security Card Information	[Page 4] Part 4. Social Security Card Information 1.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 A. in Item Number 1., skip to Item Number 2. If you answered “Yes” to Item A. in Item Number 1., provide the information requested in Item B. below. B. Provide your Social Security number (SSN) (if known). [Page 5] 2. Do you want the SSA to issue you a Social Security card? (You must also answer “Yes” to Item Number 3., Consent for Disclosure, to receive a card.) Yes No NOTE: If you answered “No” to Item Number 2., skip to Part 5. If you answered “Yes” to Item Number 2., you must also answer “Yes” to Item Number 3. 3. 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 2. - 3., provide the information requested in Item Numbers 4. - 5. 4. Father's Name Provide your father's birth name. Family Name (Last Name) Given Name (First Name) 5. Mother's Name Provide your mother's birth name. Family Name (Last Name) Given Name (First Name)	[Page 4] Part 4. Social Security Card Information [no change]
Page 5-6, Part 5. Applicant’s Statement, Contact Information, Certification, and Signature	[Page 5] Part 5. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-765 Instructions before completing this section. You must file Form I-765 while in the United States. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant’s Statement Regarding the Interpreter 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. B. The interpreter named in Part 6. 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. Applicant’s Statement Regarding the Preparer At my request, the preparer named in Part 7., [Fillable field], 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 6] Applicant's 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 may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I 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. Applicant's Signature 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 5] Part 5. Applicant's Statement, Contact Information, Certification, and Signature [no change]
Page 6-7, Part 6. Interpreter’s Contact Information, Certification, and Signature	[Page 6] Part 6. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3. Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [Page 7] 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 5., Item B. in Item Number 1., 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 Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)	[Page 6] Part 6. Interpreter's Contact Information, Certification, and Signature [no change]
Page 7-8, Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant	[Page 7] Part 7. 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. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer's Mailing Address 3. Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [Page 8] 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. 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 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 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. Preparer's Signature Date of Signature (mm/dd/yyyy)	[Page 7] Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant [No change] 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. [no change]
Page 9, Part 8. Additional Information	[Page 9] 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]	[Page 9] Part 8. Additional Information [no change]

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