.b. Given Name (First Name) 4.c. Middle Name Form 1-765 12/26/19 Page 1 of 7 EFTA00173751 Part 2. Information About You (continued) Your U.S. Mai!keg Address 5.a. In Care Of Name (if any) 5.b. Street Number and Name 5.c. 2 Apt. 0 Ste. 0 Flr. 5.d. City or Town 5.e. State Ny Nem Yock 5.1. ZIP Code