Application for Employment Authorization for Abused Nonimmigrant Spouse

• Legal Form Number: I-765V
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-765V Edition 07/21/22 N Page 1 of 7

Application for Employment Authorization for

Abused Nonimmigrant Spouse

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-765V

OMB No. 1615-0137

Expires 07/31/2025

Select this box if

Form G-28 is

attached.

Attorney State Bar Number

(if applicable) Attorney or Accredited Representative

USCIS Online Account Number (if any)

To be completed by an

Attorney or Accredited

Representative (if any).

Part 1. Reason for Applying

START HERE - Type or print in black ink.►

Initial permission to accept employment.

I am applying for:

Replacement of lost, stolen, or damaged employment

authorization document, or correction of my

employment authorization document NOT DUE to

U.S. Citizenship and Immigration Services (USCIS)

error.

NOTE: Replacement (correction) of an employment

authorization document due to USCIS error does not

require a new Form I-765V. Refer to the Form

I-765V Instructions for further details.

1.a.

1.b.

1.c. Renewal of my permission to accept employment.

(Attach a copy of your previous employment

authorization document.)

2.b.

2.c.

2.a.

Other Names Used (if any)

Family Name

(Last Name)

Given Name

(First Name)

Middle Name

Provide all other names you have ever used, including aliases,

maiden name, and nicknames. If you need extra space to

complete this section, use the space provided in Part 9.

Additional Information.

3.a.

3.b.

3.c.

Safe Mailing Address (USPS ZIP Code Lookup)

NOTE: If you do not want USCIS to send notices about this

application to your home, you may provide an alternate safe

mailing address.

Street Number

and Name

3.d. City or Town

3.e. State 3.f. ZIP Code

Flr.Ste.Apt.

In Care Of Name (if any)

If you answered "No" to Item Number 4., provide your

U.S. physical address in Item Numbers 5.a. - 5.e.

4. Is your current U.S. physical address the same as your

safe mailing address? Yes No

Authorization/Extension

Valid Through

Authorization/Extension

Valid From

For

USCIS

Use

Only Remarks

Action BlockFee Stamp

Part 2. Information About You

Your Full Name

Family Name

(Last Name)

Given Name

(First Name)

Middle Name

NOTE: USCIS will issue your card in this name.

1.a.

1.b.

1.c.