I-765 Copy Deck

I-765-044 Form Asylumworks Vacatur with no inclusion of (c)(8) v.1.2.3.pdf

Application for Employment Authorization

I-765 Copy Deck

OMB: 1615-0040

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1615-0040 can be found here:

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myUSCIS copy deck
I-765; (a)(12); (c)(3)(A); (c)(3)(B); (c)(3)(C); (c)(11); (c)(19); (c)(33) Application for Employment
OMB control number 1615-0040
Baseline version: 07/26/2022
New version: 01/31/2023
How edits are made
Explanation of Revision
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in black. All revised (new)
text will be in red. Example is
shown.
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shown in black. Any text that
is removed from original
column will be shown with a
strikethrough and in red.
Example is shown.

1. Oranges
2. Bananas
3. Apple
4. Pineapple

Revised

After

1. Oranges
2. Bananas
3. Apple
4. Pineapple

Edits Made

I-765 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Copy in gray boxes is approved copy from previous forms and should not be edited
Step: Indicates the form navigation element.
Section: Indicates the form sub-navigation element. Copy for questions should be grouped by appropriate section.
Questions/Sub-Questions: Based on the questions from the paper form.
Instructional text: Text that appears directly below a question and provides instructions for answering the question or completing this step/section of the form.
Help text: Text that appears below or next to an input field, partially hidden. Users can click to expand. Provides additional contextual or clarifying information about a question.
CTA: copy for button
Page breaks are indicated by a horizontal line (the same sub-navigation can have multiple pages)
Conditional question logic is indicated in ( ) before question
Heading

Body Text
Link
Use this form to request employment authorization and an Employment Authorization Document (EAD) https://www.uscis.gov/i-765
if your immigration status allows you to work in the United States.
Note: You may apply online if your eligibility category is:
•
(a)(12) - Temporary Protected Status (You are submitting an initial Form I-821 or you have an approved
Form I-821);
•
(c)(3)(A) - F-1 student, pre-completion OPT;
•
(c)(3)(B) - F-1 student, post-completion OPT;
•
(c)(3)(C) - F-1 student, 24-month extension for STEM students (students holding a degree in science,
technology, engineering, or mathematics);
•
(c)(11) - Parole;
•
(c)(19) - Temporary Protected Status (You have a pending Form I-821); or
•
(c)(33) - Consideration of Deferred Action for Childhood Arrivals (DACA) (You must have a pending or
approved Form I-821D in order to file Form I-765).
All other applicants must submit a paper Form I-765.

CTA

Notes

Edits Made

I-765 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Before You Start Your
Application

Eligibility

Body Text
Certain foreign nationals who are in the United States may file Form I-765, Application for Employment Authorization, to request employment authorization and an
Employment Authorization Document (EAD). Other foreign nationals whose immigration status authorizes them to work in the United States without restrictions may also use
Form I-765 to apply for an EAD that shows such authorization.

Asylumworks revisions
Certain foreign nationals who are in the United States may file Form I-765, Application for Employment Authorization, to request employment authorization and an
Employment Authorization Document (EAD). Other foreign nationals whose immigration status authorizes them to work in the United States without restrictions may also use
Form I-765 to apply to U.S. Citizenship and Immigration Services (USCIS) for an EAD that shows such authorization.

Foreign nationals may also apply for a Social Security number and card on Form I-765.

If you are a lawful permanent resident, a conditional permanent resident, or a nonimmigrant only authorized for employment with a specific employer under 8 CFR 274a.12(b),
do not use Form I-765.

Learn more about employment authorization.

You may apply online if your eligibility category is:
•
(a)(12) - Temporary Protected Status (You are submitting an initial Form I-821 or you have an approved Form I-821);
•
(c)(3)(A) - F-1 student, pre-completion OPT;
•
(c)(3)(B) - F-1 student, post-completion OPT;
•
(c)(3)(C) - F-1 student, 24-month extension for STEM students (students holding a degree in science, technology, engineering, or mathematics);
•
(c)(11) - Parole;
•
(c)(19) - Temporary Protected Status (You have a pending Form I-821); or
•
(c)(33) - Consideration of Deferred Action for Childhood Arrivals (DACA).

Link
https://www.uscis.gov/i-765

link to: https://www.uscis.gov/humanitarian/temporary-protected-status
www.ucsis.gov/i-765

CTA

Notes
Form I-765 instructions, "What Is
the Purpose of Form I-765" - page
1

Recommended language to show
online filing is only supported for
(c)(3)(A), (c)(3)(B), and
(c)(3)(C)eligibility categories

All other applicants must submit a paper Form I-765.
Please review the specific filing instructions if you are filing Form I-765 under one of the following eligibility categories:
F1 Students Seeking Optional Practical Training (OPT)

https://www.uscis.gov/i-765

(c)(3)(A) eligibility category: Submit Form I-765 up to 90 days before being enrolled as an F-1 foreign student for one full academic year at an educational institution approved by
U.S. Immigration and Customs Enforcement (ICE) and Student and Exchange Visitor Program (SEVP). Your period of employment will not start before you have completed one
full academic year. If you completed the one-year requirement while in another valid nonimmigrant status and you are now in valid F-1 status, you are still eligible to apply for
OPT.

Form I-765 instructions, "Who
May File Form I-765"- pages 6-8

(c)(3)(B) eligibility category: Submit Form I-765 up to 90 days before, but no later than 60 days after your program end date. You must submit your application within 30 days of
the date that your designated school official (DSO) enters the recommendation for OPT into your Student and Exchange Visitor Information System (SEVIS) record. If you fail to
do so, we will deny your OPT request.
(c)(3)(C) eligibility category: Submit Form I-765 application up to 90 days before your current OPT expires, but you must submit within 60 days of the DSO's approval of STEM
OPT.
Note: If you are an F-1 student filing for initial or extension of OPT, your OPT and your employment authorization will be automatically terminated if you change educational
program levels or transfer to another school. Working in the United States without authorization may result in your removal from the United States or denial of re-entry. Consult
your DSO for additional details.
Temporary Protected Status (TPS)

www.uscis.gov/tps

(a)(12) and (c)(19) eligibility categories: Submit Form I-765 with your Form I-821 application or with evidence that we accepted or approved your initial Form I-821. You must
also follow the instructions for filing your application as described in the most recent TPS Federal Register notice regarding a TPS designation, re-designation, or extension for
your country. For more information, review our instructions for TPS applicants.
Parole
(c)(11) eligibility category: File Form I-765 with a copy of your Form I-94, passport, or other travel document showing you were paroled into the United States for urgent
humanitarian reasons or reasons of significant public benefit pursuant to INA 212(d)(5) (such as Cuban Family and Haitian Family Reunification Parole programs).
Note: For individuals paroled into the United States after a positive credible fear determination — On Feb. 7, 2022, in Asylumworks et al. v. Mayorkas et al., the U.S. District
Court for the District of Columbia vacated several rules that affected applications for employment authorization filed by individuals who received positive credible fear
determinations and were subsequently paroled into the United States. Credible fear parolees may file an EAD application at any time after being paroled into the United States,
and may seek employment authorization under the (c)(11) category at the time of filing.
Consideration of Deferred Action for Childhood Arrivals

Fee

(c)(33) eligibility category: You must submit Form I-765 with Form I-821D or with proof that you previously filed Form I-821D.
Fee: $410.
TPS applicants: You must pay the Form I-765 filing fee if you are requesting an EAD as an initial TPS applicant, unless you are younger than 14 or older than 65. If you are reregistering for TPS and requesting an EAD, you must pay the Form I-765 filing fee.
Note: Your total filing fee will be shown at the end of this form. The total will include the application fee for Form I-765, biometric services fee (if required), and the fee for any
other form you are submitting with this application.

Form I-765 instructions, "What Is
the Filing Fee"- page 6
Previously approved refund
policy language for digital forms

Fee waiver: If you are requesting a fee waiver, you cannot file online. You must file a paper version of both the Form I-912, Request for Fee Waiver and Form I-765, Application
for Employment Authorization. You can review the fee waiver guidance at www.uscis.gov/feewaiver.
Refund Policy: USCIS does not refund fees, regardless of any action we take on your application, petition or request, or how long USCIS takes to reach a decision. By continuing
this transaction, you acknowledge that you must submit fees in the exact amount and that you are paying the fees for a government service.
Please refer to the instructions for the form(s) you are filing for additional information or you may call the USCIS Contact Center at 800-375-5283. For TTY (deaf or hard of
hearing) 800-767-1833.

Documents you may need

Most applicants must upload:
•
A copy of your Form I-94, Nonimmigrant Arrival-Departure Record (front and back), a printout of your electronic Form I-94 from www.cbp.gov/i94, passport, or other travel
document.
•
A copy of your last EAD (front and back). If you were not previously issued an EAD, you must submit a copy of a government-issued identity document (such as a passport)
showing your picture, name, and date of birth; a birth certificate with photo ID; a visa issued by a foreign consulate; or a national ID document with photo and/or fingerprint.
The identity document photocopy must clearly show your facial features and contain your biographical information.
•
A color passport-style photograph of yourself taken recently.
We will automatically inform you which documents and additional evidence you may need to provide as you fill out your application. These recommendations for additional
information will be based on the information you provide in the application, such as your personal history and circumstances.
Any document containing foreign language submitted to USCIS must be accompanied by a full English language translation that the translator has certified as complete and
accurate, and by the translator's certification that he or she is competent to translate from the foreign language into English.

Biometric services appointment

USCIS may require that you appear for an interview or provide biometrics (fingerprints, photograph, and/or signature) at any time to verify your identity, obtain additional
information, and conduct background and security checks, including a check of criminal history records maintained by the Federal Bureau of Investigation (FBI), before making a
decision on your application, petition, or request. After USCIS receives your application and ensures it is complete, we will inform you in writing if you need to attend a
biometric services appointment. If an appointment is necessary, the notice will provide you the location of your local or designated USCIS Application Support Center (ASC) and
the date and time of your appointment.

Form I-765 instructions,
"Required Documentation" pages 25-26

Specific to digital environment
and part of global template
previously approved by OMB

If you are required to provide biometrics, at your appointment you must sign an oath reaffirming that:
1.
You provided or authorized all information in the application;
2.
You reviewed and understood all of the information contained in, and submitted with, your application; and
3.
All of the declared information was complete, true, and correct at the time of filing.

After You Submit Your
Application

Track your case online

Respond to requests for information

If you fail to attend your biometric services appointment, USCIS may deny your application.
After you submit your form, you can track its status through your USCIS account. Sign in to your account often to check your case status and read any important
messages from USCIS.
If we need more information from you, we will send you a Request for Evidence (RFE) or Request for Information (RFI). You can respond to our request and
upload your documents through your USCIS account.

Specific to digital environment
and part of global template
previously approved by OMB
Specific to digital environment
and part of global template
previously approved by OMB

Edits Made

I-765 INTERACTIVE FORM COPY: QUESTIONS, INSTRUCTIONAL AND HELP TEXT, AND OTHER COPY

Completing Your Form
Online

Sub-Heading

Body Text

Receive your decision

The decision on Form I-765 involves a determination of whether you have established eligibility for the immigration benefit you are seeking. USCIS will notify you
of the decision in writing. If your application is approved, we will either mail your EAD to you or we may require you to visit your local USCIS office to pick it up. If
USCIS cannot approve your application, you will receive a written notice explaining the basis of your denial.

Form I-765 instructions,
"Processing Information" - page
29

Filing online

Submitting your application online is the same as mailing in a completed paper form. They both gather the same information.

Complete the Getting Started section first

You should answer all questions in the Getting Started section first so we can best customize the rest of your online form experience.

Provide as many responses as you can

You should provide as many responses as you can. Incomplete fields or sections and missing information can slow down the process after you submit your form.

We will automatically save your responses

We will automatically save your information when you select next to go to a new page or navigate to another section of the form. We will save your information for 30 days
from today, or from the last time you worked on the form.

How to continue filling out your form

After you start your form, you can sign in to your account to continue where you left off.

DHS Privacy Notice

AUTHORITIES: The information requested on this application, and the associated evidence, is collected under the Immigration and Nationality Act, 8 U.S.C. section 1324a, 8 CFR AUTHORITIES: The information requested on this application, and the associated evidence, is collected under the Immigration and Nationality Act, 8 U.S.C. section 1324a, 8 CFR
274a.12, and 8 CFR 274a.13.
274a.12, and 8 CFR 274a.13.
PURPOSE: The primary purpose for providing the requested information on this application is to determine eligibility for certain aliens who are temporarily in the United States
requesting an Employment Authorization Document. DHS uses the information you provide to grant or deny the benefit you are seeking.

Specific to digital environment
and part of global template
previously approved by OMB
Specific to digital environment
and part of global template
previously approved by OMB
Specific to digital environment
and part of global template
previously approved by OMB
Specific to digital environment
and part of global template
previously approved by OMB
Specific to digital environment
and part of global template
previously approved by OMB
Form I-765 instructions, "DHS
Privacy Notice" - page 30
Form I-765 instructions, "DHS
Privacy Notice" - page 30

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your Social Security number, and any requested
evidence may delay a final decision or result in a rejection or denial of your application.

Form I-765 instructions, "DHS
Privacy Notice" - page 30

Paperwork Reduction Act

Security reminder

Asylumworks revisions

Link

CTA

Notes

ROUTINE USES: DHS may, where allowable under relevant confidentiality provisions, share the information you provide on this application and any additional requested
evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine uses, as described in the associated
published system of records notices [DHS/USCIS/ICE/CBP- 001 Alien File, Index, and National File Tracking System of Records; DHS/USCIS-007 Benefits Information System;
DHS/USCIS-010 Asylum Information and Pre-Screening System of Records; DHS/USCIS-017 Refugee Case Processing and Security Screening Information System of Records; and
DHS/USCIS-018 Immigration Biometric and Background Check (IBBC) System of Records], and the published privacy impact assessments [DHS/USCIS/PIA-016(a) Computer Linked
Application Information Management System (CLAIMS 3) and Associated Systems; DHS/USCIS/PIA-027 USCIS Asylum Division; DHS/USCIS/PIA-056 USCIS Electronic Immigration
System (USCIS ELIS); and DHS/USCIS/PIA-068 Refugee Case Processing and Security Vetting], which can be found at www.dhs.gov/privacy. DHS may also share this information as
appropriate for law enforcement purposes or in the interest of national security.

ROUTINE USES: DHS may, where allowable under relevant confidentiality provisions, share the information you provide on this application and any additional requested
evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine uses, as described in the associated
published system of records notices [DHS/USCIS-001 – Alien File, Index, and National File Tracking System; DHS/USCIS-007 – Benefit Information System; DHS/USCIS-010 –
Asylum Information and Pre-Screening System of Records; and DHS/USCIS-017 Refugee Case Processing and Security Screening Information System] and DHS/USCIS-018
Immigration Biometric and Background Check (IBBC) System of Records], the published privacy impact assessments [DHS/USCIS/PIA-016(a) Computer Linked Application
Information Management System (CLAIMS 3) and Associated Systems; DHS/USCIS/PIA-027 Asylum Division; DHS/USCIS/PIA-056 USCIS Electronic Immigration System (USCIS
ELIS); and DHS/USCIS/PIA-068 Refugee Case Processing and Security Vetting], which you can find at www.dhs.gov/privacy. DHS may also share this information as appropriate
for law enforcement purposes or in the interest of national security.

Form I-765 instructions, "DHS
Privacy Notice" - page 31

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid
Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 4 hours per response, including the time
for reviewing instructions, gathering the required documentation and information, completing the application, preparing statements, attaching necessary documentation, and
submitting the application. The collection of biometrics is estimated to require 1 hour and 10 minutes. The public reporting burden for the collection of information for Form I765WS is estimated at 30 minutes per response, including the time for reviewing instructions, gathering the required documentation and information, completing the
application, preparing statements, attaching necessary documentation, and submitting the application. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden, to:

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid
Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 4 hours and 30 minutes per response,
including the time for reviewing instructions, gathering the required documentation and information, completing the application, preparing statements, attaching necessary
documentation, and submitting the application. The collection of biometrics is estimated to require 1 hour and 10 minutes. The public reporting burden for the collection of
information for Form I-765WS is estimated at 30 minutes per response, including the time for reviewing instructions, gathering the required documentation and information,
completing the application, preparing statements, attaching necessary documentation, and submitting the application. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to:

Form I-765 instructions,
"Paperwork Reduction Act" page 31

U.S. Citizenship and Immigration Services
Office of Policy and Strategy, Regulatory Coordination Division
5900 Capital Gateway Drive, Mail Stop #2140
Camp Springs, MD 20588-0009

Do not mail your completed I-765 application to this address.

OMB No. 1615-0040
Expires: 08/31/2022

OMB No. 1615-0040
Expires: 01/31/2023

If you do not work on your application for more than 30 days, we will delete your data in order to prevent storing personal information indefinitely.

Start

Specific to digital environment
and part of global template
previously approved by OMB

NO Edits Made

I-765: GETTING STARTED

The Getting Started step is the first part of the form that the applicant will complete. Questions relating to the applicant's basis for eligibility (if applicable) and questions about the applicant's preparer/interpreter (if any) should be grouped in the Getting Started step of the form and should be organized by the appropriate section. This step and section structure will inform the
navigation and sub-navigation for the form.
Primary Nav

Secondary Nav

Getting Started Basis of eligibility

Reason for applying

Tertiary Nav

Paper Form Logic
Question

Question

Sub-Question

Field Type

2.27

What is your eligibility category?

Eligibility Category

Dropdown

2.28.a

(if 2.27= c3c)

What is your degree?

Text

2.28.b

(if 2.27= c3c)

What is your employer's name as listed in E-Verify?

Text

2.28.c

(if 2.27= c3c)

What is your employer's E-Verify company identification
number or a valid E-Verify client company identification
number?

Text

1.1.a

(if 2.27=
What is your reason for applying?
a12/c3a/c3b/c3c/c
11)
(if 2.27=
a12/c3a/c3b/c3c/c
11/c19/c33)

1.1.b

1.1.c

2.12

Radio
Radio

(IF YES) Is a preparer assisting you with completing this
application?

Yes/No

Radio

(IF YES) Is an interpreter assisting you with completing this
application?

Yes/No

Radio

5.1.b

What is your preparer's full name?

Given name (first name)

Text

5.1.a
5.2

What is your preparer's business or organization name?

Family name (last name)

Text
Text

5.3.a.-5.3.h.

What is your preparer's mailing address?

My preparer is not part of a business or organization.
Country

Checkbox
Dropdown

What is your preparer's contact information?

Address line 1
Address line 2
City or town
State/Province
ZIP code/Postal code
Daytime phone number

Text
Text
Text
Dropdown/Text
Text
Text

4.1.b

What is your interpreter's full name?

Mobile telephone number
My preparer does not have a mobile telephone number
Email address
My preparer does not have an email address.
Given name (first name)

Text
Checkbox
Text
Checkbox
Text

4.1.a
4.2

What is your interpreter's business or organization name?

Family name (last name)

Text
Text

4.3

What is your interpreter's mailing address?

My interpreter is not part of a business or organization.
Country

Checkbox
Dropdown

Address line 1
Address line 2
City or town
State/Province
ZIP code/Postal code

Text
Text
Text
Dropdown/Text
Text

5.5
5.6
(IF YES TO
INTERPRETER)
Interpreter information

Notes

Required field

b. Replacement of lost, stolen, or damaged employment Radio
authorization document, or correction of my employment
authorization document NOT DUE to U.S. Citizenship and
Immigration Services (USCIS) error.
c. Renewal of permission to accept employment.
Radio

Yes/No
Yes/No

5.4

Help Text

Required field

Radio

Have you previously filed Form I-765?
Is someone assisting you with completing this application?

Preparer and
interpreter information

(IF YES TO PREPARER
QUESTION) Preparer
information

(if 2.27=
a12/c3a/c3b/c3c/c
11/c19)

a. Initial permission to accept employment.

Instructional Text

Specific to digital environment and part of
global template previously approved by OMB.

A preparer is anyone who completes or
helps you complete all or part of your
application using information and
answers that you provide.
An interpreter is anyone who translates
or helps you translate all or part of your
application using information and
answers that you provide.

Street number and name
Apartment, suite, unit, or floor

Specific to digital environment and part of
global template previously approved by OMB.

NO Edits Made

I-765: GETTING STARTED

Secondary Nav

Tertiary Nav

Paper Form Logic
Question

Question

Sub-Question

Field Type

4.4

What is your interpreter's contact information?

Daytime telephone number

Text

4.5

Mobile telephone number
Text
My interpreter does not have a mobile telephone number Checkbox

4.6
What language is your interpreter using to interpret this
application for you?

Email address
My interpreter does not have an email address.

Text
Checkbox
Text

Instructional Text

Help Text

Notes

Edits Made

INTERACTIVE FORMS: ABOUT YOU

The About You step is the second part of the paper form that the applicant will complete. Questions relating to the applicant's personal information should be grouped in the About you step of the form and should be organized by the appropriate section. This step and section structure will inform the navigation
and sub-navigation for the form. Personal information questions include questions about the applicant's name, contact information, immigration information, demographics, school and employment, military service, requests for accommodations, etc.
About You should be the THIRD TAB when creating a new copydeck.
Primary Nav

Secondary Nav

About You

Your name

Tertiary Nav

Paper Form Question
Question

2.1.b

2.1.c
2.1a

Your contact
information

Given name (first name)

Middle name
Family name (last name)
Yes/No

2.2c
2.2a
3.3

How may we contact you?

Middle name
Family name (last name)
Daytime telephone number

Text (9 digits)

3.4

Mobile telephone number (if any)

Text (9 digits)
Checkbox

3.5
2.5.a

This is the same as my daytime
telephone number.
Email address
In care of name (if any)

Address line 1
Address line 2
City or town
State
ZIP code
Yes/No

Text
Text
Text
Dropdown
Text
Radio

Is your current mailing address the
same as your physical address?

2.7.b
2.7.c
2.7.d
2.7.e
2.10

(If no) Where in the United States do Address line 1
you live?
Address line 2
City or town
State
ZIP code
What is your gender?
Male/Female

2.12

What is your marital status?

2.19a

What is your city, town, or village of
birth?

Help Text

Other names used may include nicknames,
aliases, and maiden names.

Given name (first name)

What is your current U.S. mailing
address?

Instructional Text

Notes

Your current legal name is the name on your
birth certificate, unless it changed after birth by a
legal action such as marriage or court order. Do
not provide any nicknames here.

(If yes)

2.7.a

When and where
you were born

Have you used any other names
since birth?

Field Type

2.2b

2.5.b
2.5.c
2.5.d
2.5.e
2.5.f
2.6

Describe yourself

What is your current legal name?

Sub-Question

Required field

Provide the other names you have used.

Text
Text

We will use your current mailing address to
contact you throughout the application process.
We may not be able to contact you if you do not
provide a complete and valid address. Please
provide a U.S. address only.
Street number and name
Apartment, suite, unit, or floor

Required field
Required field
Required field

Text

Street number and name

Text
Text
Dropdown
Text
Radio

Apartment, suite, unit, or floor

Single, Married, Divorced, Widowed Radio

Text

Required field

Edits Made

INTERACTIVE FORMS: ABOUT YOU

Secondary Nav

Your immigration
information

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

2.19b

What is your state or province of
birth?

2.19c
2.20

What is your country of birth?
What is your date of birth?

2.18

What is your country of citizenship or
nationality?

Dropdown

2.21.a

What is your Form I-94 ArrivalDeparture Record Number (if any)?

11 character
restricted
text

2.22
2.23

2.24
2.21.b

When did you last arrive in the United
States?

What is the passport number of your
most recently issued passport?

(mm/dd/yyyy)

Dropdown
Date

Date of arrival (on or about)
Place of arrival

Date
Dropdown

Status at last arrival

Dropdown
Text

What is your travel document number
(if any)?

Text

2.21.e

What is the expiration date of your
(mm/dd/yyyy)
passport or travel document?
What country issued your passport or Country
travel document?
What is your current immigration status
or category?

Date

2.25

Help Text

Notes

Text

2.21c

2.21.d

Instructional Text

Dropdown
Dropdown

Required field

List all countries where you are currently
a citizen or national.

List your arrival date, place of arrival, and
status at arrival.

User will be able to input multiple
countries (at least two based on paper
form). It will be a table or list.

mm/dd/yy

Edits Made

INTERACTIVE FORMS: ABOUT YOU

Secondary Nav

Other information

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

Instructional Text

2.26

N-

Text

A-

Text (9 digits)

Use the "Additional Information" section
to include all previously used SEVIS
numbers.

2.8

2.9

2.13a

What is your Student and Exchange
Visitor Information System (SEVIS)
Number (if any) ?
What is your A-Number?

I do not have or know my A-Number.
What is your USCIS Online Account
Number?

Checkbox
Text (12
digits)

I do not have or know my USCIS Online
Account Number.
Has the Social Security
Administration (SSA) ever officially
issued a Social Security card to
you?

Checkbox
Yes/No

Radio

2.13b

(If yes to 2.13a) What is your Social
Security number (if known)?

Text (9 digits)

2.14

Do you want the SSA to issue you a Yes/No
Social Security card?

Radio

2.15

(If yes to 2.14) Consent for
Yes/No
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.

Radio

2.16b

(If yes to 2.15) What is your father's Given name (first name)
birth name?

Text

2.16a
2.17b

Family name (last name)
(If yes to 2.15) What is your mother's Given name (first name)
birth name?

Text
Text

Help Text

Providing your unique USCIS Online
The phrase "certain paper forms" would have a
Account Number (OAN) helps us manage tooltip that would list the forms: "I-90, I-130, I-485, Iyour account. You may already have an 821, I-821D, N-336, N-400, N-565, N-600, N-600K"
OAN if you previously filed certain paper
forms and received an Account Access
Notice in the mail. You can find the OAN
at the top of the notice; it is not the
same as an A-Number.

Notes

Edits Made

INTERACTIVE FORMS: ABOUT YOU

Secondary Nav

Tertiary Nav

Paper Form Question
Question

Sub-Question

Field Type

2.17a

Family name (last name)

Text

Instructional Text

Help Text

Notes

Edits Made

INTERACTIVE FORMS: EVIDENCE

The Evidence step is for forms that require the applicant to submit evidence to USCIS. As the applicant completes the form, the form's logic will dictate which pieces of evidence a particular applicant should be prompted to submit.
Evidence should be a separate tab when creating a new copydeck for forms that collect this information.
f
Primary Nav
Evidence

l b id tifi d i th Gl b l C
Secondary Nav
2 x 2 photo of you

d th

h ld b
Logic

d Thi

i it
t t t
Paper Form
Form I-765 instructions, "Required Documentation" pages 25-26

Evidence Title
2 x 2 Photo of You

Instructional Text
Upload a recent color photograph of yourself that measures 2 inches by 2 inches, with your face measuring 1 inch to 1 3/8
inch from your chin to the top of your head. Your eyes should be between 1 1/8 inch and 1 3/8 inch from the bottom of the
photo.

Field Type
Upload

Links
https://travel.state.gov/cont
ent/travel/en/us-visas/visainformationresources/photos.html

Upload

•
Clear and readable
Accepted file formats: JPG, JPEG, PDF, TIF or
https://www.cbp.gov/travel •
/international-visitors/i-94 TIFF
•
No encrypted or password-protected files
www.uscis.gov/i-102
•
If your documents are in a foreign language,
upload a full English translation and the
translator's certification with each original
document.
•
Upload no more than five documents at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens,
underscores, and parentheses
•
Maximum size: 12MB per file

Make sure your whole face is visible, you are facing the camera directly, and the background is white or off-white. Your head
must be bare, unless contrary to your religious beliefs.
If you need help understanding the photo requirements or want to resize, rotate, or crop your photo, you can use the
Department of State's photo composition tools. Please note that we cannot approve your application without your photo.

File requirements
•
Clear and readable
•
Accepted file formats: JPG, JPEG, or PNG
•
No encrypted or password-protected files
•
If your documents are in a foreign language,
upload a full English translation and the
translator's certification with each original
document.
•
Upload no more than one document at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens,
underscores, and parentheses
•
Maximum size: 12MB per file

NOTES
https://travel.state.gov/cont
ent/travel/en/us-visas/visainformationresources/photos.html

(if all)
Form I-765 instructions, "Required Documentation" page 25

Form I-94

I-94, Arrival and Departure
Record

Upload a copy of one of the following:
•
Your Form I-94, Arrival-Departure Record (front and back);
•
A printout of your electronic Form I-94 ; or
•
Your passport or other travel document.
If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, CBP may have issued you an
electronic Form I-94 instead of a paper Form I-94. You may visit the CBP website to obtain a paper version of an electronic
Form I-94. CBP does not charge a fee for this service. Some travelers admitted to the United States at a land border, airport,
or seaport, after April 30, 2013, with a passport or travel document, who were issued a paper Form I-94 by CBP, may also be
able to obtain a replacement Form I-94 from the CBP website without charge.
If your Form I-94 cannot be obtained from the CBP website, it may be obtained by filing Form I-102, Application for
Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a fee for this service.

https://www.cbp.gov/travel
/international-visitors/i-94
www.uscis.gov/i-102

(if all)
Employment Authorization Document

Form I-765 instructions, "Required Documentation" page 25

Employment Authorization
Document or Government ID

Upload a copy of your last Employment Authorization document (EAD) (front and back). If you were not previously issued an
EAD, you must upload a copy of a government-issued identity document (such as a passport) showing your picture, name,
and date of birth; a birth certificate with photo ID; a visa issued by a foreign consulate; or a national ID document with photo
and/or fingerprint. The identity document photocopy must clearly show your facial features and contain your biographical
information.

Upload

•
Clear and readable
•
Accepted file formats: JPG, JPEG, PDF, TIF or
TIFF
•
No encrypted or password-protected files
•
If your documents are in a foreign language,
upload a full English translation and the
translator's certification with each original
document.
•
Upload no more than five documents at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens,
underscores, and parentheses
•
Maximum size: 12MB per file

Form I-765 instructions, "Who May File Form I-765"page 7

Proof of Enrollment

Upload evidence of having been lawfully enrolled on a full-time basis for one full academic year at a college, university,
conservatory, or seminary approved by the U.S. Immigration and Customs Enforcement (ICE) Student and Exchange Visitor
Program (SEVP) for attendance by F-1 foreign students.

Upload

Proof of enrollment

(if all)
(if c3a)

Previously authorized CPT or OPT

(if c3a or c3b)

Form I-765 instructions, "Who May File Form I-765"pages 7-8

Previously authorized CPT or
OPT

Upload evidence of any previously authorized CPT or OPT and the academic level at which it was authorized.

Upload

Form I-20

(if c3a, c3b, c3c)

Form I-765 instructions, "Who May File Form I-765"pages 7-8

I-20, Certificate of Eligibility for
Nonimmigrant Student Status

Upload a copy of the Form I-20, Certificate of Eligibility for Nonimmigrant Student Status endorsed by the Designated School
Official (DSO). For the (c)(3)(B) eligibility category, your DSO must have entered the recommendation for OPT into your SEVIS
record within 30 days of you submitting Form I-765. If you fail to do so, we will deny your OPT request. For the (c)(3)(C)
eligibility category, the Form I-20 must have been endorsed by the DSO within 60 days of submitting Form I-765.

Upload

College degree

(if c3c)

Form I-765 instructions, "Who May File Form I-765"page 8

College Degree

Upload evidence that the degree that is the basis for the STEM OPT extension is in one of the degree programs currently
listed on the STEM Designated Degree Program List or a copy of your prior STEM degree.

Upload

https://studyinthestates.dhs
.gov/stem-opt-hub/eligiblecip-codes-for-the-stem-optextension

Edits Made

INTERACTIVE FORMS: EVIDENCE

l b id tifi d i th Gl b l C
Secondary Nav
Institution accreditation

d th

h ld b
Logic
(if c3c)

d Thi

i it
t t t
Paper Form
Form I-765 instructions, "Who May File Form I-765"page 8

Instructional Text
Upload evidence that the institution that granted your STEM degree is currently accredited by the U.S. Department of
Education and certified by the Student Exchange and Visitor Program (SEVP), if this STEM OPT extension is based on a
previously earned STEM degree.

Proof of Temporary Protected
If you are submitting a first-time re-registration with USCIS following an Immigration Judge or Board of Immigration
Status Granted by EOIR Immigration Appeals decision granting your TPS application, upload a copy of the TPS decision order.
Judge or Board of Immigration
Appeals

(if a12/c19)

EOIR or BIA order

Evidence Title
Institution Accreditation

Field Type
Upload

Upload

If you previously filed Form I-821, upload evidence that we accepted or approved your initial Form I-821.

Upload

I-821D, Consideration Of
Deferred Action For Childhood
Arrivals (DACA)

If you previously filed Form I-821D, upload evidence that you have a pending or approved Form I-821D.

Upload

•
Clear and readable
•
Accepted file formats: JPG, JPEG, PDF, TIF or TIFF
•
No encrypted or password-protected files
•
If your documents are in a foreign language, upload
a full English translation and the translator's
certification with each original document.
•
Upload no more than five documents at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens, underscores,
and parentheses
•
Maximum size: 12MB per file

I-765WS, Worksheet

Download, complete, and upload Form I-765WS so that we can determine whether you have an economic need for work.

Form I-765 instructions, "Who May File Form I-765" page
6
(if a12/c19)

(if a12/c19)

Upload proof of your identity and nationality. Examples of documents you may submit include copies of your:

Form I-821D

Form I-765WS

Form I-765 instructions, "Who May File Form I-765" page
6
Proof of Identity and Nationality
I-821, Application for Temporary
Protect Status

Form I-765 instructions, "Who May File Form I-765" page
6

Form I-821

File requirements
•
Clear and readable
•
Accepted file formats: JPG, JPEG, PDF, TIF or
TIFF
•
No encrypted or password-protected files
•
If your documents are in a foreign language,
upload a full English translation and the
translator's certification with each original
document.
•
Upload no more than five documents at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens,
underscores, and parentheses
•
Maximum size: 12MB per file

Upload

•
Passport (cover to cover);
•
Birth certificate accompanied by photo identification; or
•
Any national identity document from your country of origin that includes your photo and/ or fingerprint.

Proof of identity and nationality

Links

(if c33)

•
Clear and readable
•
Accepted file formats: JPG, JPEG, PDF, TIF or TIFF
•
No encrypted or password-protected files
•
If your documents are in a foreign language, upload
a full English translation and the translator's
certification with each original document.
•
Upload no more than five documents at a time
•
Accepted file name characters: English letters,
numbers, spaces, periods, hyphens, underscores,
and parentheses
•
Maximum size: 12MB per file

NOTES

NO Edits Made

I-765: ADDITIONAL INFORMATION
Questions from the paper form should be identified in the Global Copydeck and the same copy should be used. This copy has been approved for use in its current state.
Step: Indicates the form navigation element. In this case, these questions would appear in the Getting Started step of the form.
Section: Indicates the form sub-navigation element. The following copy for questions is grouped by the section in which they should appear.
Questions/Sub-Questions: Based on the questions from the paper form.
Help text: Text that appears below or next to an input field, partially hidden. Users can click to expand. Provides additional contextual or clarifying information about a question.
Instructional text: Text that appears directly below a question and provides instructions for answering the question.
Question sets are separated by a double-line.
Conditional question logic is indicated in () before question.
Primary
Additional
Information

Secondary
Paper Form Question Question
Additional information 6.1.a-6.7.d
You may provide additional information for your application

Sub-Question
Field Type Required? Instructional Text
Help Text Notes
Additional information Textbox No
If you need to provide any additional information for any of your
answers to the questions in this form, enter it into the space below. You
should include the questions that you are referencing.
If you do not need to provide any additional information, you may leave
this section blank.

(if 2.27=

Edits Made

INTERACTIVE FORMS: REVIEW AND SUBMIT

The Review and Submit step is the last step that an applicant completes before submitting their form. Sections and Questions in the Review and Submit step should be mostly consistent across all forms but copy should be updated to reflect the statements, certification, and attestations on the paper form. Review and Submit should contain all of the copy relating to reviewing the application, the preparer/interpreter's certification and signature, the applicant's
statements and signature, and paying/submitting the application.
Review and Submit should be the LAST TAB when creating a new copydeck for a form.
Primary Nav

Review and Submit

Secondary Nav
Review your application

Tertiary Nav

Paper Form

Question
Check your application before you submit

Sub-Question

Field Type

Instructional Text
We will review your application to check for accuracy and completeness before you
submit it.

Help Text

CTA

Notes
Specific to digital environment and part of
global template previously approved by OMB.

We encourage you to provide as many responses as you can throughout the
application, to the best of your knowledge. Missing information can slow down the
review process after you submit your application.
You can return to this page to review your application as many times as you want
before you submit it.
Your form filing fee is: [$XXX}

Your fee

Exact fee will be pulled from ELIS

Refund Policy: USCIS does not refund fees, regardless of any action we take on
your application, petition or request, or how long USCIS takes to reach a decision.
By continuing this transaction, you acknowledge that you must submit fees in the
exact amount and that you are paying the fees for a government service.

You have one or more alerts and warnings based on the information you provided in
your application.

Alerts and warnings

Your application summary

A red alert means you have incomplete responses or inconsistent data. You cannot
submit your application with any alerts.
Here is a summary of all the information you provided in your application.

Review the I-765 form information

Make sure you have provided responses for everything that applies to you before
you submit your application. You can edit your responses by going to each
application section using the site navigation.

Specific to digital environment and part of
global template previously approved by OMB.

We also prepared a draft case snapshot with your responses, which you can
download below.

(IF PREPARER) Preparer
statement

5.7a

Preparer's statement

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with
the applicant's consent.

Radio

Your preparer must read the statements below and select the statement that applies to him
or her.
If your preparer is an attorney or accredited representative whose representation extends
beyond preparation of this application, he or she may be obliged to submit a completed
Notice of Entry of Appearance as Attorney or Accredited Representative (G-28) with your
application.

5.7b
5.7b
5.8a

Preparer's certification and signature

I am an attorney or accredited representative and my representation of the applicant in this case does not extend beyond
the preparation of this application.
I am an attorney or accredited representative and my representation of the applicant in this case extends beyond the
preparation of this application.
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.

Radio
Radio
Your preparer must read and agree to the certification below.

As the applicant's preparer, you must sign on paper and provide your signature page to the applicant. Follow these steps:
1.
2.
3.
4.

Specific to digital environment and part of
global template previously approved by OMB.

Download the Preparer Signature page
Print the Preparer Signature page
Read and sign the Preparer Signature page
Give the signed Preparer Signature page to the applicant

The applicant will need to scan and upload your completed signature page on the next screen.
(IF PREPARER) Preparer
signature
(IF INTERPRETER)
Interpreter certification

Preparer's signature upload
4.7a

Interpreter's certification and signature

Upload
I certify, under penalty of perjury, that: I am fluent in English and the language provided in the Getting Started section of
this application, 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.

Scan and upload your preparer's completed signature page below.
Your interpreter must read and agree to the certification below.

As the applicant's interpreter, you must sign on paper and provide your signature page to the applicant. Follow these
steps:
1.
2.
3.
4.

Specific to digital environment and part of
global template previously approved by OMB.

Download the Interpreter Signature page
Print the Interpreter Signature page
Read and sign the Interpreter Signature page
Give the signed Interpreter Signature page to the applicant

The applicant will need to scan and upload your completed signature page on the next screen.
(IF INTERPRETER)
Interpreter signature
Your statement

Interpreter's signature upload
3.1a

Applicant's statement

3.2

Applicant's statement regarding the preparer

3.1b

Applicant's statement regarding the interpreter

I can read and understand English, and have read and understand every question and instruction on this application, as
well as my answer to every question.
At my request, the preparer named in the Getting Started section of this application prepared this application for me
based only upon the information I provided or authorized.
The interpreter named in the Getting Started section of this application read to me every question and instruction on this application
and my answer to every question in the language I specified in the Getting Started section, a language in which I am fluent, and I
understood everything.

Upload

Scan and upload your interpreter's completed signature page below.

Checkbox

You must read and agree to the statement below.

Checkbox

You must read and agree to the statement below.

Checkbox

You must read and agree to the statement below.

Edits Made

INTERACTIVE FORMS: REVIEW AND SUBMIT

Secondary Nav
(If "Your Statement" is
complete) Your signature

Tertiary Nav

Paper Form

Question

Sub-Question

Form I-765, "Applicant's
Declaration and
Certification" - pages 4-5

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.

Field Type

Instructional Text

Help Text

CTA

Notes

You must read and agree to the certification below. If you knowingly and willfully
falsify or conceal a material fact or submit a false document with your application,
we can deny your application and may deny any other immigration benefit. You may
also face criminal prosecution and penalties provided by the law.

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 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.

I have read and agree to the applicant's statement

3.7a

Your signature

[Date of signature]
Pay for and submit your application

(If "Your Statement" and
"Your signature" are
complete ) Pay and submit

Checkbox

Specific to digital environment and part of
global template previously approved by OMB.
You must provide your digital signature below by typing your full legal name. If you do not
completely fill out this application, or if you do not submit the required documents listed in
the Instructions, we may deny your application. We will record the date of your signature
with your application.

Required field

The final step to submit your Form I-765, Application for Employment Authorization
is to pay the required fee.

Exact fee will be pulled from ELIS

Your application fee is: [$XXX]
Refund policy: By continuing this transaction, you agree that you are paying for a
government service and that the filing fee, biometric services fee and all related
financial transactions are final and not refundable, regardless of any action USCIS
takes on an application, petition or request, or how long USCIS takes to reach a
decision. You must submit all fees in the exact amounts.

We will send you to Pay.gov — our safe, secure payment website — to pay your
fees and submit your application online.

Pay and submit

Here are the steps in the payment and submission process:
1. Provide your billing information on Pay.gov
2. Provide your credit card or U.S. bank account information
3. Submit your payment
When you have paid your fee, your application will be submitted.
Pay.gov will redirect you to a uscis.gov confirmation screen, which will include your
receipt number. Please keep a copy of your receipt number for your records. You
can track the status of your application through your USCIS online account.

( Sucessful subnmission)
(No nav)

You have successfully submitted your Application
for Employment Authorization (1-765)

(Unsuccesful card declined)
(No nav)

You did not submit your Application for
Employment Authorization (1-765)

( Unsucessful subnmission)
(No nav)

You did not submit your Application for Employment
Authorization (1-765)

We will contact you if we have any questions or need additional information. You can track
the status of your application through your USCIS online account.
Your payment failed because your credit or debit card was declined.
You can try again now to sign and submit your applications or save and exit.
Your payment failed or was canceled before it could be processed on Pay.gov.
You can try again now to sign and submit your application or save your application and exit.
We will save your application for 30 days from when you started it.

Go to my cases

Sign and submit

Specific to digital environment and part of
global template previously approved by OMB.

I-765: Alerts
Number Section

About You, Additional
information

Type

Logic

Yellow alert

User selects "No" to consent
statement regarding SSN

Message

Notes

h2. You must agree to the Consent for Disclosure
To receive a Social Security card, you must select "Yes" to the Consent for Disclosure.
https://www.uscis.gov/sites/default/files/document/forms/i-765.pdf
h2. You can file your request online only for certain eligibility categories

Getting Started, Basis of
eligibility
Yellow alert

Getting Started,
Additional information Yellow alert
Getting Started, Basis of Yellow alert
eligibility

Always displays

User selects "Yes" to "Do you
want the SSA to issue you a
Social Security card"
If user selects a12 or c19

If your eligibility category does not appear on the drop-down list, you must file a paper
Form I-765. If you submit online and are not eligible for one of the listed categories, your
application may be denied.

h2. You must agree to the Consent for Disclosure
f you answer “Yes”, you must also answer “Yes” to the Consent for Disclosure.
h2. Only certain TPS applicants may apply online
To apply under this eligibility category online, you must be filing an initial application for
TPS and an eligible national of Burma, Syria, Venezuela, or Yemen, or a person without
nationality who last habitually resided Burma, Syria, Venezuela, or Yemen. If you do not
meet these requirements, please submit a paper Form I-765. If you file online and you
are not allowed to, we may deny your application.

Getting Started, Basis of Blue alert
eligibility

if users selects c11

Getting Started, Basis of Yellow alert
eligibility

if users selects c33

h2. You can now file an EAD application after being paroled into the United States
Pursuant to the Feb. 7, 2022 ruling in Asylumworks et al. v. Mayorkas et al., credible fear
parolees may file an EAD application at any time after being paroled into the United States, and
may seek employment authorization under the (c)(11) category at the time of filing.

h2. You must file Form I-821D or currently have DACA
Based on the EAD eligibility category you selected and your A-number, you cannot submit a
Form I-765, Application for Employment Authorization until you have filed an initial or renewal
Form I-821D, Consideration for Deferred Action for Childhood Arrivals (DACA), or your request
for DACA (initial or renewal) has been approved.
If you have not yet filed Form I-821D, return to the "File a Form" page and select "Form I-821D,
Consideration of Deferred Action for Childhood Arrivals." from the drop-down menu to file
your request for DACA first. After you complete and pay for your Form I-821D, you will then be
able to file Form I-765 online. If you already have a Form I-821D pending or were recently
approved for DACA, please upload your receipt notice for your pending Form I-821D or the
decision notice USCIS issued approving your request for DACA.
If you continue to file the Form I-765 and fail to provide evidence of a pending or approved
Form I-821D, we will reject your application and you will not receive a refund of the filing fee.

link to: https://www.uscis.gov/humanitarian/temporary-protected-status

I-765: Alerts
Number Section
Evidence, I-821D

Type

Logic

Message

Yellow alert

if no evidence uploaded

h2. Provide proof of your pending or approved Form I-821D
Please upload a copy of your receipt notice for your pending Form I-821D or the decision notice
USCIS issued approving your request for DACA. If you continue to file Form I-765 and fail to
provide evidence of a pending or approved Form I-821D, we will reject your application and
you will not receive a refund of the filing fee.

Review and Submit

Red alert

If user has not answered
required field

h2. There are errors in (Section): (Sub section)
Edit my response

Notes

File Type	application/pdf
File Title	Copy of I-130 Form Copydeck 6.18.19- acaOCC 062719
Author	Microsoft Office User
File Modified	2022-08-24
File Created	2022-08-24