Application for Employment Authorization for Abused Nonimmigrant Spouse Department of Homeland Security U.S. Citizenship and Immigration Services Fee Stamp USCIS Form I-765V OMB No. 1615-0137 Expires 01/31/2019 For USCIS Use Only Action Block AEAD Code Assigned: (c) Initial Receipt Resubmitted Application Approved Completed Approved Denied Returned Relocated Received Sent Application Denied Remarks Authorization/Extension Valid From Authorization/Extension Valid To 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. Part 1. Information About You 1. I am applying for: Initial permission to accept employment. Replacement. (Lost, stolen, mutilated card, or my card contains incorrect information not attributed to U.S. Citizenship and Immigration Services (USCIS) error.) Renewal of my permission to accept employment. (Attach a copy of your previous employment authorization document.) 2. Alien Registration Number (A-Number) (if any) Other Names Used (if any) 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 7. Additional Information. 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name A3. USCIS Online Account Number (if any) Safe Mailing Address NOTE: If you do not want USCIS to send notices about this application to your home, you may provide an alternate safe mailing address. 7.a. In Care Of Name (if any) 7.b. Street Number and Name 7.c. Apt. Ste. Flr. 4. U.S. Social Security Number (if any) Your Full Name NOTE: USCIS will issue your card in this name. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 7.d. City or Town 7.e. State 8. 7.f. ZIP Code Is your current U.S. physical address the same as your safe mailing address? Yes No If you answered "No" to Item Number 8., provide your U.S. physical address in Item Numbers 9.a. - 9.e. Form I-765V 01/19/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 6 Part 1. Information About You (continued) U.S. Physical Address 9.a. Street Number and Name 9.b. Apt. Ste. Flr. 19.b. Date Current Status Expired or Will Expire, as shown on Form I-94 (mm/dd/yyyy) 19.c. Passport Number 19.d. Travel Document Number 19.e. Country of Issuance for Passport or Travel Document 9.c. City or Town 9.d. State 9.e. ZIP Code 19.f. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 20. Female 21. Current Immigration Status (for example, A-2, E-3, G-1, H-4, No Lawful Status) Eligibility Category. Refer to the Who May File Form I-765V section of the Form I-765V Instructions to determine the appropriate eligibility category for this application. In the space below, enter the letter and number for your eligibility category. (For example, (c)(27), (c)(28), (c)(29), (c)(30)). Other Information 10. 11. Sex Male Date of Birth (mm/dd/yyyy) 12.a. City or Town of Birth 12.b. State or Province of Birth 12.c. Country of Birth Part 2. Information About Your Spouse 13. Country of Citizenship or Nationality Provide the following information, if known. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. 3. Approved Denied Date of Birth (mm/dd/yyyy) Country of Birth 14. Have you EVER applied for employment authorization from USCIS? Yes No If you answered "Yes" to Item Number 14., provide the information requested in Item Numbers 15.a. - 15.b. for your most recent application. 15.a. Which USCIS Office? 15.b. What was the result? NOTE: Attach all documentation from your previous employment authorization. 16. Place of Last Entry into the United States U.S. Physical Address 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 17. 18. Date of Last Entry into United States, on or about (mm/dd/yyyy) Immigration Status of Last Entry (for example, A-2, E-3, G-1, H-4) 4.c. City or Town 4.d. State 4.e. ZIP Code Other Information 5. A-Number (if any) 19.a. Form I-94 Arrival-Departure Record Number (if any) A- Form I-765V 01/19/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 6 Part 2. Information About Your Spouse (continued) 6. USCIS Online Account Number (if any) Part 4. Applicant's Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-765V Instructions before completing this part. You must file Form I-765V while in the United States. 7.a. Form I-94 Arrival-Departure Record Number (if any) Applicant's Statement 7.b. Passport Number 7.c. Travel Document Number 7.d. Country of Issuance for Passport or Travel Document NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.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. The interpreter named in Part 5. read to me every question and instruction on this application and my answer to every question in , a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 6., , prepared this application for me based only upon information I provided or authorized. 7.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 8. Your Spouse's Nonimmigrant Status (Select only one box) A-1 G-2 H-1B1 H-3 A-2 G-3 H-1C A-3 G-4 H-2A E-3 G-5 H-2B G-1 H-1B H-2R 1.b. Other (Use the space provided in Part 7. Additional Information) Part 3. Marriage Information Your Current Marital Status (Select only one box) 1.a. Married Applicant's Contact Information 3. Applicant's Daytime Telephone Number 1.b. Date of Marriage (mm/dd/yyyy) 1.c. City or Town of Marriage 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) 1.d. Country of Marriage Applicant's Declaration and Certification 2.a. Divorced 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 and all information from any 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 sup