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NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, you may have

been issued an electronic Form I-94 by CBP, instead of a paper Form I-94. You may visit the CBP website at

to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this service. Some

travelers admitted to the United States at a land border, airport, or seaport, after April 30, 2013, with a passport or travel

document, who were issued a paper Form I-94 by CBP, may also be able to obtain a replacement Form I-94 from the CBP

website without charge. If your Form I-94 cannot be obtained from the CBP website, it may be obtained by filing Form

I-102, Application for Replacement/Initial Nonimmigrant Arrival-Departure Record, with USCIS. USCIS does charge a

fee for this service.

Passport and Travel Document Numbers. If you used a passport or travel document to travel to the United States, enter

either the passport or travel document information in the appropriate space on the application, even if the passport or

travel document is currently expired.

Item Number 20. Current Immigration Status. Provide the letter and number that correlates with your current

immigration status. If you are present in the U.S. without lawful immigration status, type or print, “No Lawful Status.”

Item Number 21. Eligibility Category. Provide the eligibility category under which you are requesting employment

authorization: (c)(27) – abused spouse of A nonimmigrant, (c)(28) – abused spouse of E-3 nonimmigrant, (c)(29) –

abused spouse of G nonimmigrant, or (c)(30) – abused spouse of H nonimmigrant.

Part 2. Information About Your Spouse

Provide the information requested in this section, if known. If you need extra space to complete this section, use the space

provided in Part 7. Additional Information. If you do not know the answer to a question, type or print “unknown,”

unless otherwise directed. Submit evidence to demonstrate the legal status of your spouse. This may include a copy of

his or her passport, travel document information, or evidence of his or her A-Number.

Although you may not be able to provide documentary evidence of your spouse’s nonimmigrant status, you must provide

some identifying evidence such as name, place of birth, country of birth, date of birth, date of entry into the United States,

Form I-94 Number, employer, etc. USCIS will conduct a search of the appropriate electronic systems to attempt to verify

the qualifying nonimmigrant status of the spouse.

Item Numbers 1.a. - 1.c. Your Spouse’s Full Name. Provide your spouse’s full legal name in the spaces provided. Do

not use nicknames.

Item Number 2. Date of Birth. Type or print your spouse’s date of birth using the mm/dd/yyyy format. For example,

type or print October 5, 1967 as 10/05/1967.

Item Number 3. Country of Birth. Type or print the name of the country where your spouse was born.

Item Numbers 4.a. - 4.e. U.S. Physical Address. Provide the address where your spouse currently resides.

Item Number 5. A-Number (if any). Type or print your spouse’s A-Number. An A-Number is typically issued to

persons who apply for, or are granted, certain immigration benefits. ICE, CBP, EOIR, and DOS, in addition to USCIS,

may issue an A-Number to certain aliens. If your spouse was issued an A-Number, type or print it in the spaces provided.

Item Number 6. USCIS Online Account Number. If your spouse has previously filed an application, petition, or

request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),

provide the USCIS Online Account Number your spouse was issued by the system. The USCIS Online Account Number

is not the same as an A-Number.

Item Numbers 7.a. - 7.e. Form I-94 Arrival-Departure Record. If CBP or USCIS issued your spouse a Form I-94,

Arrival-Departure Record, provide your spouse’s Form I-94 number and date that your spouse’s 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.

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 5