Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse Page 3

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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.
Applicant's Contact Information
Part 3. Marriage 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
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