Part 2. Information About You (continued)
If you answered “Yes” to Item Number 30.c., provide the following information:
30.d. Date you presented yourself to DHS
30.e. Location where you presented yourself to DHS
30.f. Country of claimed persecution
30.g. Provide an explanation for why you did not enter the United States lawfully through a U.S. port of entry. If you need extra space to complete this item, use the space provided in Part 6. Additional Information.
NOTE: Refer to the Special Filing Instructions for Those With Pending Asylum Applications (c)(8) section of the Form
I-765 Instructions for more information.
31.a. (c)(35) and (c)(36) Eligibility Category. If you entered the eligibility category (c)(35) in Item Number 27., please provide the receipt number of your Form I-797 Notice for Form I-140, Immigrant Petition for Alien Worker. If you entered the eligibility category (c)(36) in Item Number
27., please provide the receipt number of your spouse's or parent's Form I-797 Notice for Form I-140.
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31.b. If you entered the eligibility category (c)(35) or (c)(36) in Item Number 27., have you EVER been arrested for
and/or convicted of any crime? |
Yes |
No |
NOTE: If you answered “Yes” to Item Number 31.b., refer to Employment-Based Nonimmigrant Categories, Items 8. - 9., in the Who May File Form I-765 section of the Form I-765 Instructions for information about providing court dispositions.
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-765 Instructions before completing this section. You must file Form I-765 while in the United States.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.
1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question.
1.b. The interpreter named in Part 4. read to me every question and instruction on this application and my answer to every question in
,
a language in which I am fluent, and I understood everything.
2.
At my request, the preparer named in Part 5.,
,
prepared this application for me based only upon information I provided or authorized.
Applicant's Contact Information
3.Applicant's Daytime Telephone Number
4.Applicant's Mobile Telephone Number (if any)
5.Applicant's Email Address (if any)
6.
Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC settlement agreement.
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.