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Passport and Travel Document Numbers. If your spouse used a passport or travel document to travel to the United

States, enter either the passport or travel document information (if available) in the appropriate space on the application,

even if the passport or travel document is currently expired.

Item Number 8. Your Spouse’s Nonimmigrant Status. Indicate your spouse’s nonimmigrant status by selecting the

appropriate classification.

Part 3. Marriage Information

Submit a copy of your marriage certificate or other evidence to demonstrate that you have a qualifying relationship with

your spouse listed in Part 2.

Item Numbers 1.a. - 5.b. Your Current Marital Status. Select only one box and provide the information related to

your selection.

Part 4. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature

Item Numbers 1.a. - 6.b. Select the appropriate box to indicate whether you read this application yourself or whether

you had an interpreter assist you. If someone assisted you in completing the application, select the box indicating that you

used a preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile

telephone number (if any), and email address (if any). Every application MUST contain the signature of the applicant (or

parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

Part 5. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1.a. - 7.b. If you used anyone as an interpreter to read the Instructions and questions on this application to

you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and

address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone

number (if any), and his or her email address (if any). The interpreter must sign and date the application.

Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than

the Applicant

Item Numbers 1.a. - 8.b. This section must contain the signature of the person who completed your application, if other

than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete

both Part 5. and Part 6. If the person who completed this application is associated with a business or organization,

that person should complete the business or organization name and address information. Anyone who helped you

complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature

is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he

or she may be obliged to also submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited

Representative, along with your application.

Part 7. Additional Information

Item Numbers 1.a. - 7.d. If you need extra space to provide any additional information within this application, use the

space provided in Part 7. Additional Information. If you need more space than what is provided in Part 7., you may

make copies of Part 7. to complete and file with your application, or attach a separate sheet of paper. Type or print your

name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to

which your answer refers; and sign and date each sheet.

We recommend that you print or save a copy of your completed application to review in the

future and for your records.

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 6