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DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and

any requested evidence, may delay a final decision or result in the denial of your benefit request.

ROUTINE USES: The information you provide in the application is confidential and protected from disclosure under

8 USC 1367. The information will be used by and disclosed to DHS personnel and contractors or other agents in

accordance with approved routine uses, as described in the associated published system of records notices [DHS-

USCIS-001 - Alien File, Index, and National File Tracking System of Records and DHS-USCIS-007 – Benefit

Information System] which you can find at

DHS may also make the information available, as

appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

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 3 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. Send comments regarding this burden estimate or

any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship

and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW,

Washington, DC 20529-2140; OMB No. 1615-0137. Do not mail your completed Form I-765V to this address.

Complete this Checklist Before Mailing Form I-765V

Unless stated otherwise, provide photocopies of original documents.

Form I-765V properly signed by you. An original signature or reproduction of an original signature is required.

Two passport-style color photographs

Evidence of your qualifying nonimmigrant status as a spouse who accompanied or followed-to-join a principal

nonimmigrant admitted under INA section 101(a)(15) subparagraph (A), (E)(iii), (G), or (H).

Evidence of your spouse’s nonimmigrant status (if available).

Copies of your marriage certificate or other supporting documentation you may have to demonstrate that you have a

qualifying spousal relationship to your spouse.

For initial applicants for employment authorization, evidence that you or your children were subjected to battery

and/or extreme cruelty by your nonimmigrant spouse.

Form I-765V Instructions 01/19/17 N

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Instructions For Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse Page 10