Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse Page 4
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6Interpreter'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
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