USCIS Form I-765V "Application for Employment Authorization for Abused Nonimmigrant Spouse"

What Is USCIS Form I-765V?

This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on January 19, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 19, 2017;
  • The latest available edition released by the U.S. Department of Homeland Security - Citizenship and Immigration Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of USCIS Form I-765V by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.

ADVERTISEMENT
ADVERTISEMENT

Download USCIS Form I-765V "Application for Employment Authorization for Abused Nonimmigrant Spouse"

1329 times
Rate (4.8 / 5) 92 votes
Application for Employment Authorization for
Abused Nonimmigrant Spouse
USCIS
Form I-765V
Department of Homeland Security
OMB No. 1615-0137
U.S. Citizenship and Immigration Services
Expires 01/31/2019
Action Block
Fee Stamp
For USCIS Use Only
A-
EAD Code Assigned: (c)
Initial Receipt
Completed
Relocated
Remarks
Approved
Received
Resubmitted
Denied
Sent
Returned
Authorization/Extension Valid From
Application
Application Denied
Approved
Authorization/Extension Valid To
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
To be completed by an
(if applicable)
USCIS Online Account Number (if any)
Form G-28 is
Attorney or Accredited
attached.
Representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You
Other Names Used (if any)
Provide all other names you have ever used, including aliases,
1.
I am applying for:
maiden name, and nicknames. If you need extra space to
Initial permission to accept employment.
complete this section, use the space provided in Part 7.
Replacement. (Lost, stolen, mutilated card, or my
Additional Information.
card contains incorrect information not attributed to
Family Name
6.a.
U.S. Citizenship and Immigration Services (USCIS)
(Last Name)
error.)
Given Name
6.b.
(First Name)
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
6.c.
Middle Name
authorization document.)
2.
Alien Registration Number (A-Number) (if any)
Safe Mailing Address
A-
NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
3.
USCIS Online Account Number (if any)
mailing address.
7.a.
In Care Of Name (if any)
4.
U.S. Social Security Number (if any)
7.b.
Street Number
and Name
Your Full Name
7.c.
Apt.
Ste.
Flr.
NOTE: USCIS will issue your card in this name.
7.d. City or Town
5.a.
Family Name
(Last Name)
7.e. State
7.f.
ZIP Code
5.b.
Given Name
(First Name)
8.
Is your current U.S. physical address the same as your
5.c.
Middle Name
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
Page 1 of 6
Application for Employment Authorization for
Abused Nonimmigrant Spouse
USCIS
Form I-765V
Department of Homeland Security
OMB No. 1615-0137
U.S. Citizenship and Immigration Services
Expires 01/31/2019
Action Block
Fee Stamp
For USCIS Use Only
A-
EAD Code Assigned: (c)
Initial Receipt
Completed
Relocated
Remarks
Approved
Received
Resubmitted
Denied
Sent
Returned
Authorization/Extension Valid From
Application
Application Denied
Approved
Authorization/Extension Valid To
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
To be completed by an
(if applicable)
USCIS Online Account Number (if any)
Form G-28 is
Attorney or Accredited
attached.
Representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You
Other Names Used (if any)
Provide all other names you have ever used, including aliases,
1.
I am applying for:
maiden name, and nicknames. If you need extra space to
Initial permission to accept employment.
complete this section, use the space provided in Part 7.
Replacement. (Lost, stolen, mutilated card, or my
Additional Information.
card contains incorrect information not attributed to
Family Name
6.a.
U.S. Citizenship and Immigration Services (USCIS)
(Last Name)
error.)
Given Name
6.b.
(First Name)
Renewal of my permission to accept employment.
(Attach a copy of your previous employment
6.c.
Middle Name
authorization document.)
2.
Alien Registration Number (A-Number) (if any)
Safe Mailing Address
A-
NOTE: If you do not want USCIS to send notices about this
application to your home, you may provide an alternate safe
3.
USCIS Online Account Number (if any)
mailing address.
7.a.
In Care Of Name (if any)
4.
U.S. Social Security Number (if any)
7.b.
Street Number
and Name
Your Full Name
7.c.
Apt.
Ste.
Flr.
NOTE: USCIS will issue your card in this name.
7.d. City or Town
5.a.
Family Name
(Last Name)
7.e. State
7.f.
ZIP Code
5.b.
Given Name
(First Name)
8.
Is your current U.S. physical address the same as your
5.c.
Middle Name
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
Page 1 of 6
19.b.
Date Current Status Expired or Will Expire, as shown on
Part 1. Information About You (continued)
Form I-94 (mm/dd/yyyy)
U.S. Physical Address
19.c.
Passport Number
9.a. Street Number
and Name
19.d.
Travel Document Number
9.b.
Apt.
Ste.
Flr.
19.e.
Country of Issuance for Passport or Travel Document
9.c. City or Town
19.f.
Expiration Date for Passport or Travel Document
9.d. State
9.e. ZIP Code
(mm/dd/yyyy)
Other Information
20.
Current Immigration Status (for example, A-2, E-3, G-1,
H-4, No Lawful Status)
10.
Sex
Male
Female
11.
Date of Birth (mm/dd/yyyy)
Eligibility Category. Refer to the Who May File Form
21.
I-765V section of the Form I-765V Instructions to
12.a. City or Town of Birth
determine the appropriate eligibility category for this
application. In the space below, enter the letter and
number for your eligibility category. (For example,
12.b.
State or Province of Birth
(c)(27), (c)(28), (c)(29), (c)(30)).
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)
14.
Have you EVER applied for employment authorization
1.b. Given Name
from USCIS?
Yes
No
(First Name)
If you answered "Yes" to Item Number 14., provide the
1.c. Middle Name
information requested in Item Numbers 15.a. - 15.b. for
your most recent application.
2.
Date of Birth (mm/dd/yyyy)
15.a.
Which USCIS Office?
Country of Birth
3.
15.b.
What was the result?
Approved
Denied
U.S. Physical Address
NOTE: Attach all documentation from your previous
4.a. Street Number
employment authorization.
and Name
16.
Place of Last Entry into the United States
4.b.
Apt.
Ste.
Flr.
4.c. City or Town
17.
Date of Last Entry into United States, on or about
(mm/dd/yyyy)
4.d. State
4.e. ZIP Code
18.
Immigration Status of Last Entry (for example, A-2, E-3,
G-1, H-4)
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
Page 2 of 6
Part 4. Applicant's Statement, Contact
Part 2. Information About Your Spouse
Information, Declaration, Certification, and
(continued)
Signature
6.
USCIS Online Account Number (if any)
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
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
7.c.
Travel Document Number
1.a.
I can read and understand English, and I have read
7.d.
Country of Issuance for Passport or Travel Document
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 5. read to me every
7.e. Expiration Date for Passport or Travel Document
question and instruction on this application and my
(mm/dd/yyyy)
answer to every question in
8.
Your Spouse's Nonimmigrant Status (Select only one box)
,
A-1
A-2
A-3
E-3
G-1
a language in which I am fluent, and I understood
everything.
G-2
G-3
G-4
G-5
H-1B
2.
At my request, the preparer named in Part 6.,
H-1B1
H-1C
H-2A
H-2B
H-2R
,
H-3
Other (Use the space provided in Part 7.
prepared this application for me based only upon
Additional Information)
information I provided or authorized.
Part 3. Marriage Information
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
Your Current Marital Status (Select only one box)
1.a.
Married
4.
Applicant's Mobile Telephone Number (if any)
1.b.
Date of Marriage (mm/dd/yyyy)
1.c.
City or Town of Marriage
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
2.b.
Date of Divorce (mm/dd/yyyy)
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
3.a.
Widowed
any and all information from any of my records that USCIS
may need to determine my eligibility for the immigration
3.b.
Date of Spouse's Death
benefit that I seek.
(mm/dd/yyyy)
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
4.
Separated
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
5.a.
Marriage Annulled
5.b.
Date of Annulment (mm/dd/yyyy)
Form I-765V 01/19/17 N
Page 3 of 6
Interpreter's Contact Information
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
4.
Interpreter's Daytime Telephone Number
Signature (continued)
I certify, under penalty of perjury, that all of the information in
5.
Interpreter's Mobile Telephone Number (if any)
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
6.
Interpreter's Email Address (if any)
application and that all of this information is complete, true, and
correct.
Applicant's Signature
Interpreter's Certification
6.a.
Applicant's Signature (sign in ink)
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 4., Item Number
6.b.
Date of Signature (mm/dd/yyyy)
1.b., and I have read to this applicant in the identified language
NOTE TO ALL APPLICANTS: If you do not completely fill
every question and instruction on this application and his or her
out this application or fail to submit required documents listed
answer to every question. The applicant informed me that he or
in the Instructions, USCIS may deny your application.
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.
Part 5. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Signature
Provide the following information about the interpreter.
7.a.
Interpreter's Signature (sign in ink)
Interpreter's Full Name
7.b.
Date of Signature (mm/dd/yyyy)
1.a.
Interpreter's Family Name (Last Name)
Part 6. Contact Information, Declaration, and
1.b.
Interpreter's Given Name (First Name)
Signature of the Person Preparing this
Application, if Other Than the Applicant
2.
Interpreter's Business or Organization Name (if any)
Provide the following information about the preparer.
Preparer's Full Name
Interpreter's Mailing Address
1.a. Preparer's Family Name (Last Name)
3.a.
Street Number
and Name
1.b.
Preparer's Given Name (First Name)
3.b. Apt.
Ste.
Flr.
3.c. City or Town
2.
Preparer's Business or Organization Name
3.d. State
3.e. ZIP Code
3.f.
Province
3.g. Postal Code
3.h. Country
Form I-765V 01/19/17 N
Page 4 of 6
Part 6. Contact Information, Declaration, and
Preparer's Certification
Signature of the Person Preparing this
By my signature, I certify, under penalty of perjury, that I
Application, if Other Than the Applicant
prepared this application at the request of the applicant. The
(continued)
applicant then reviewed this completed application and
informed me that he or she understands all of the information
Preparer's Mailing Address
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
3.a.
Street Number
information is complete, true, and correct. I completed this
and Name
application based only on information that the applicant
3.b. Apt.
Ste.
Flr.
provided to me or authorized me to obtain or use.
3.c. City or Town
Preparer's Signature
3.d. State
3.e. ZIP Code
8.a. Preparer's Signature (sign in ink)
3.f.
Province
8.b. Date of Signature (mm/dd/yyyy)
3.g. Postal Code
3.h. Country
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
I am not an attorney or accredited representative
7.a.
but have prepared this application on behalf of
the applicant and with the applicant's consent.
I am an attorney or accredited representative and
7.b.
my representation of the applicant in this case
does not extend beyond the
extends
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.
Form I-765V 01/19/17 N
Page 5 of 6