NOTE: This Is Sample I-765 Form. You May Find That Some Fields Do Not .

NOTE: This is a sample I-765 form. You may find that some fields do not apply to you. If unsure, please contact ISSS with questions.

IPart 2. Information About You (continued)YQur lJ.S. M'aillng Addres I14.tUSPSZlP-l'odc totikupJ5.a. In Care Of Name (if any)NOTE: If you answered "No" to Item Number 14., skipto Part 2., Item Number IS.a. If you answered "Yes" toItem Number 14., you must also answer "Yes" to ItemEddie Cappie5.b. Street Number J 100South 100Westand Name5.c.0 Apt. D Ste. D Fir.5.d. City or Town5.e.6.State 5.f.Number 15.[ 1 ---- ' S a It L ak e C ity-----' ZIP Code ' 8 4 1 1 2, Is your current mailing address the same as your physicaladdress? Yes D NoNOTE: If you answered "No" to Item Number 6.,provide your physical address below.7.c.City or TownMother's Name' S a It L ak e C ity.2ZIP Code ' 8 4 1 1 ,Alien Registration Number (A-Number) (if any) A-19 :s 7 6 5 4 3I9.USCIS Online Account Number (if any) OEl10.GenderI I.Marital Status12.JNIA(Last Name) -.16.b. Given NameNIA(First Name)Ofher lnformalion8.NOTE: If you answered "Yes" to Item Numbers14. - 15., provide the information requested in ItemNumbers 16.a. - 17.b.16.a. Family Name0 Fir.7.d. State 7.e.Consent for Disclosure: I authorize disclosure ofinformation from this application to the SSA as requiredfor the purpose of assigning me an SSN and issuing me aSocial Security card.D Yes D NoProvide your father's birth name.7.a. street Number J 100South 100Westand Name0 Ste.15.Father's Namel!.S. Physical .Address7.b. Ci] Apt.Do you want the SSA to issue you a Social Security card?(You must also answer "Yes" to Item Number 15.,Consent for Disclosure, to receive a card.)D Yes No Male2 1D Female0 Single D Married D Divorced D WidowedHave you previously filed Form I-765? YesD Noofficially issued a Social Security card to you? YesONoProvide your mother's birth name.17.a. Family Name J NIA(Last Name) - .17.b. Gi ven NameNIA(First Name) -.JYour Cou11try or,Cou11111ies o/Citizentrhip orNationalityList all countries where you are currently a citizen or national.If you need extra space to complete this item, use the spaceprovided in Part 6. Additional Information.IIS.a. CountryNeverland18.b. CountryNIA13.a. Has the Social Security Administration (SSA) everNOTE: If you answered "No" to Item Number 13.a.,skip to Item Number 14. If you answered "Yes" to ItemNumber 13.a., provide the information requested in ItemNumber 13.b.I13.b. Provide your Social Security number (SSN) (if known). Form 1-765 Edition 08/25/20I 2 3 45 6 78 0Page 2 of7NOTE: This is a sample I-765 form. You may find that some fields do not apply to you. If unsure, please contact ISSS with questions.

!Part 2. Information About You (continued)1/nformation About Your EligibilitJ! Category27.Place of BirthList the city/town/village, state/province, and country whereyou were born.19.a. City/fown/Villagc of BirthI Whoville(G]l{ l(0l28.19.b. State/Province of BirthI Crumpit Province19.c. Country of BirthNeverlandI20.Date of Birth (mm/dd/yyyy)28.b. Employer'sName as Listed in E-Vcrify[ ABCD Agency01/27/199228.c. Employer's E-Verify Company Identification Number or aValid E-Verify Client Company Identification Number1 12345621.a. Form 1-94 Arrival-Departure RecordNumber (if any) 1123 4 56 78929.0 02 l.b. PassportNumber ofYour Most Recently Issued PassportI A OOOOOOOl 2345621.c. Travel DocumentNumber (if any)IN/AI21.d. Country That IssuedYour Passport or Travel Document[Neverland21.e. Expiration Date for Passport or Travel Document(mm/dd/yyyy)[ 09/25/202523.24.Date ofYour Last Arrival Into the United States, On orAbout (mm/dd/yyyy)OJ /05/2020JPlace ofYour Last Arrival Into the United StatesLos AngelesJImmigration Status atYour Last Arri val (for example,B-2 visitor, F-1 student, or no status)I F-1 Student25. Your Current Immigration Status or Category (for example,B-2 visitor, F-1 student, parolee, deferred action, or nostatus or category)[ F-1 Student26.(c)(3)(C) STEM OPT Eligibility Category. If youentered the eligibility category (c)(3)(C) in Item Number27., provide the infonnation requested in Item Numbers28.a. - 28.c.28.a. Degree I Master's Computer ScienceInformation About Your Last Arrival in theUnited States22.Eligibility Category. Refer to the Who May File FormI-765 section of the Form I-765 Instructions to determinethe appropriate eligibility category for this application.Enter the appropriate letter and number for your eligibilitycategory below (for example, (a)(8), (c)(l7)(iii)).Student and Exchange Visitor Information System(SEVIS) Number (if any) --- - - -- 00000012345 N-1Form 1-765 Edition 08/25/20(c)(26) Eligibility Category. If you entered the eligibilitycategory (c)(26) in Item Number 27., provide the receiptnumber of your H-1B spouse's most recent Form 1-797Notice for Form 1-129, Petition for NonimmigrantaWorker.I NON E30.(c)(8) Eligibility Category If you entered the eligibilitycategory (c)(8) in Item Number 27., provide theinfonnation requested in Item Numbers 30.a. - 30.g.30.a. Have you EVER been arrested for, and/or charged with,and/or convicted of any crime in any country?DYes D NoNOTE: If you answered "Yes"to Item Number 30.a.,refer to Special Filing Instructions for Those WithPending Asylum Applications (c)(8) of the Form I-765Instructions for information about providing courtdispositions.30.b. Did you enter the United States lawfully through a U.S.port of entry and were you inspected and admitted orparoled after inspection by an immigration officer? (Ifyou answer Y" es,"you MUST provide evidence of yourlawful entry.)DYes D No30.c. If you answered N" o"to Item Number 30.b., did youpresent yourself to the Secretary of Homeland Security orhis or her delegate (DHS) within 48 hours of entry orattempted entry AND express an intention to seek asylumwithin the United States or express a fear of persecutionor torture in your home country?DYesNo Page 3 of7NOTE: This is a sample I-765 form. You may find that some fields do not apply to you. If unsure, please contact ISSS with questions.

jPart 2. Information About You (continued)If you answered "Yes" to Item Number 30.c., provide thefollowing information:30.d. Date you presented yourself to OHS.-, N-/A----.30.e. Location where you presented yourself to OHSI NIAPart 3. Applicantt s Statement, Contactlnfbrmatlon, Declaration Certification, andSignatureNOTE: Read the Penalties section of the Form 1-765Instructions before completing this section. You must fileForm I-765 while in the United States.Applicant' Statement30.f. Country of claimed persecutionNOTE: Select the box for either Item Number I.a. or l.b. Ifapplicable, select the box for Item Number 2.30.g. Provide an explanation for why you did not enter theI.a.NIAUnited States lawfully through a U.S. port of entry. Ifyou need extra space to complete this item, use the spaceprovided in Part 6. Additional Information.l.b.2.NOTE: Refer to the Special Filing Instructions for ThoseWith Pending Asylum Applications (c)(8) section of the FormI-765 Instructions for more information.31.a. (c)(35) and (c)(36) Eligibility Category. If you enteredthe eligibility category (c)(35) in Item Number 27., pleaseprovide the receipt number of your Form 1-797 Notice forForm 1-140, Immigrant Petition for Alien Worker. If youentered the eligibility category (c)(36) in Item Number27., please provide the receipt number of your spouse's orparent's Form 1-797 Notice for Form 1-140. O N EIN31.b. If you entered the eligibility category (c)(35) or (c)(36) inItem Number 27., have you EVER been arrested forand/or convicted of any crime?D Yes D NoNOTE: If you answered "Yes" to Item Number 31.b.,refer to Employment-Based Nonimmigrant Categories,Items 8. - 9., in the Who May File Form 1-765 section ofthe Form I-765 Instructions for information aboutproviding court dispositions.Q I can read and understand English, and I have readand understand every question and instruction on thisapplication and my answer to every question.DDThe interpreter named in Part 4. read to me everyquestion and instruction on this application and myanswer to every question ina language in which I am fluent, and I understoodeverything.At my request, the preparer named in Part 5.,prepared this application for me based only uponinformation I provided or authorized.Applicant' Contact ln/Qrmatio113.4.5.6.Applicant's Daytime Telephone NumberI 8011002000Applicant's Mobile Telephone Number (if any)18011002000Applicant' Email Address (if any)j eddiecappie@gmail.comDSelect this box if you are a Salvadoran or Guatemalannational eligible for benefits under the ABCsettlement agreement.Applicant' Declaration and CertificationCopies of any documents I have submitted are exact photocopiesof unaltered, original documents, and I understand that USCISmay require that I submit original documents to USCIS at a laterdate. Furthermore, I authorize the release of any informationfrom any and all of my records that USCIS may need todetermine my eligibility for the immigration benefit that I seek.I furthermore authorize release of information contained in thisapplication, in supporting documents, and in my USCJSrecords, to other entities and persons where necessary for theadministration and enforcement of U.S. immigration law.Form I-765 Edition 08/25/20Page 4 of7NOTE: This is a sample I-765 form. You may find that some fields do not apply to you. If unsure, please contact ISSS with questions.