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. Marital Status 18.a. Country Single O Married O Divorced O Widowcd LovAiz. I 12. Have you previously filed Form 1-765? OYes ENo 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? @Yes O No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. I

Stamp Action Block Valid From • Authorization/Extension Valid Through Alien Registration Number A- Remarks To be completed by an attorney or Board of Immigration Appeals (BIA)- accredited representative (if any). K Select this box if Form C-28 Is attached. Attorney or Accredited Representative USCIS Online Account

your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mothers birth name. 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? 0 NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you ans

Fee Stamp Action Block 0 Authorization/Extension K Valid Through Allen Registration Number A-L i I Remarks To be completed by an attorney or Board of Immigration Appeals (BIA)- accredited representative (if any). O Select this box if Form G-28 is attached. Attorney or Accredited Representative USCIS Online Accoun

your father's birth name. 16.a. Family Name (Last Name) 16.b. Given Name (First Name) Mother's Name Provide your mothers birth name. 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? 0 NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you ans

Fee Stamp Action Block 0 Authorization/Extension K Valid Through Allen Registration Number A-L i I Remarks To be completed by an attorney or Board of Immigration Appeals (BIA)- accredited representative (if any). O Select this box if Form G-28 is attached. Attorney or Accredited Representative USCIS Online Accoun

arital Status 18.a. Coun Eraingle K Married K Divorced K Widowed 12. Have you previously filed Form I-765? 18.b. Country ❑Yes E'No 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ErYes K No NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14.

From For Authorization/Extension Valid Through USCIS Use Only Alien Registration Number A- I I I Remarks To be completed by an attorney or Board of Immigration Appeals (13IA)- accredited representative (if any). Select this box if Form G-28 is attached. Attorney or Accredited Representative USCIS Online Account