Uscis Form I-765ws - Form I-765 Worksheet
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1USCIS
Form I-765 Worksheet
Form I-765WS
Department of Homeland Security
OMB No. 1615-0040
U.S. Citizenship and Immigration Services
Expires 04/30/2016
If you are applying for employment authorization under the (c)(14), Deferred Action, or (c)(33), Consideration of Deferred Action for
Childhood Arrivals, categories, you must complete this worksheet so that USCIS can determine whether you have an economic need
to work. In the spaces provided, please indicate your current annual income, your current annual expenses, and the total current value
of your assets. It is not necessary to submit supporting documentation, though it will be accepted and reviewed if you choose to
submit it. You do not need to include other household members' financial information to establish your own economic necessity.
Part 1. Full Name
1.a. Family Name
Applicant
(Last Name)
1.b. Given Name
Joseph
(First Name)
1.c. Middle Name
Patrick
Part 2. Financial Information
2.
My current annual income is:
$
18000
3.
My current annual expenses are:
$
9000
4.
The total current value of my assets is:
$
3000
Part 3. Explanation
If you would like to provide an explanation regarding your current financial information or your economic need for employment
authorization, please use the space below.
After graduating high school, I have been working in order to support my family and
myself. I barely make enough to cover our expenses. I am in need of employment
authorization to find stable work here in the United States and continue supporting my
family.
Form I-765WS 04/01/13 N
Page 1 of 1
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