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Item Number 4. U.S. Social Security Number (if any). If the Social Security Administration (SSA) ever issued a Social

Security card to you in your name or a previously used name, such as your maiden name, then you must enter the Social

Security number from your card in the space provided. If you do not have a Social Security number issued to you by the

SSA, type or print “none” in the space provided.

Item Numbers 5.a. - 5.c. Your Full Name. Provide your full legal name in the spaces provided as it appears on your

birth certificate or legal change of name document.

Item Numbers 6.a.- 6.c. Other Names Used (if any). Provide all other names you have ever used since birth, including

aliases, maiden name, and nicknames.

Item Numbers 7.a. - 8. Safe Mailing Address. If you do not feel safe receiving correspondence regarding this

application at your residential address, provide an alternate or safe mailing address in Part 1., Item Numbers 7.a. - 7.f.

You may provide a post office box (PO Box) or the address of a friend, your attorney, a community-based organization

that is helping you, or any other address where you can safely and punctually receive mail. If an alternate or safe mailing

address is not provided in Part 1., Item Numbers 7.a. - 7.f., USCIS may use the address of your preparer, if any. If your

safe mailing address is not the same as the address where you currently reside, provide your U.S. physical address in Item

Numbers 9.a. - 9.e.

Item Numbers 9.a. - 9.e. U.S. Physical Address. Provide the physical address where you currently reside in the United

States.

Item Number 10. Sex. Select the box that indicates whether you are male or female.

Item Number 11. Date of Birth. Enter your date of birth using the mm/dd/yyyy format. For example, type or print

October 5, 1967 as 10/05/1967.

Item Numbers 12.a. - 12.c. Place of Birth. Provide the name of the city or town, state or province, and country where

you were born. Provide the name of the country as it was named when you were born, even if the country’s name has

changed or the country no longer exists.

Item Number 13. Country of Citizenship or Nationality. Provide the name of the country where you are currently a

citizen or national.

Item Numbers 14. - 15.b. Prior Employment Authorization (if any). Indicate whether you previously applied for

employment authorization. If you previously applied for employment authorization, provide the USCIS office and the

results of that application.

Item Number 16. Place of Last Entry into the United States. Provide the location where you last entered the United

States.

Item Number 17. Date of Last Entry Into the United States. Provide the date of your most recent arrival into the

United States in the mm/dd/yyyy format.

Item Number 18. Immigration Status at Last Entry. Provide the letter and number that correlates with your

immigration status when you last entered or re-entered the United States.

Item Numbers 19.a. -19.f. Form I-94 Arrival-Departure Record. If CBP or USCIS issued you a Form I-94, Arrival-

Departure Record, provide your Form I-94 number and date that your authorized period of stay expires or expired (as

shown on Form I-94). The Form I-94 number also is known as the Departure Number on some versions of Form I-94.

If you do not know your Form I-94 number, type or print “unknown” in the space provided. If you were never issued a

Form I-94, type or print “none” in the space provided.

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 4