Liberian Deferred Enforced Departure (DED) Supplement to Form I-765 (United States)
This is a supplemental form to Form I-765 for Liberian deferred enforced departure from the United States. The form provided here is simply a sample of what the actual Form I-765D looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
Liberian Deferred Enforced Departure (DED) Supplement to Form I-765
I am applying for an employment authorization document (EAD) based on Liberian Deferred Enforced Departure (DED):
Part A. Information About You.
1. Complete Last Name _______________________________
2. First Name _______________________________
3. Middle Name _______________________________
4. Alien Registration Number (A-Number) or I-94 Number (if known) _______________________________
Part B. Application Type.
United States as of September 29, 2001. Since that date I have been continuously present in the United States, or if I departed from the United States, I obtained advance parole prior to all departures, or was inspected or admitted. (If you traveled outside the United States after September 29, 2001, explain below.)
Part C. Additional Eligibility Information.
1. Have you ever been arrested, convicted and sentenced or imprisoned in your country, any other country, or the United States?
____ NO ____ YES (If YES, for each instance specify below the dates, locations, and reasons or charges. Attach documents, if available, referring to these incidents. Documents showing the disposition of a conviction may be valuable in expediting processing and eliminating the need for personal interview. Do not report non-criminal traffic or immigration arrests and violations.)
2. Have you ever ordered, incited, assisted or otherwise participated in the persecution of any person because of his or her race, religion, nationality, membership in a particular social group, or political opinion?
____ NO ____ YES (If YES, describe below each such incident and your own involvement in it.)
3. Did you settle in a country other than Liberia prior to arriving in the United States?
____ NO ____ YES
4. Have you ever returned to Liberia or your country of last residence outside the United States since September 29, 2001?
____ NO ____ YES (If YES, specify below your departure and return dates, countries visited, reason for travel, and description of INS travel authorization for each such trip. Provide copies of available related documentation, especially INS documents and the pages of your passport indicating your identity and all entries and departures.)
5. Have you ever been deported, excluded, or removed from the United States before September 29, 2001? (Only answer YES to this question if there has been an actual departure from the United States.)
____ NO ____ YES (If YES, specify below to the best of your knowledge whether deported, excluded, or removed and give the departure and return dates. Provide copies of available related documentation, especially INS documents and the pages of your passport indicating your identity and all entries and departures.)
6. Have you ever been the subject of extradition proceedings?
____ NO ____ YES (If YES, specify below the date, location, and reasons or charges. Attach documents, if available referring to the extradition.)
Part D. Signature. Read the information on penalties before completing this section.
I certify under penalty of perjury under the laws of the United States of America, that this information is true and correct. I authorize release of any information from my records which the Immigration and Naturalization Service needs to determine my eligibility for the benefit being sought.
Print Name _______________________________
Part E. Signature of person preparing form if other than above.
I declare that I prepared this form at the request of the above person and it is based on all information of which I have any knowledge.
Print Name _______________________________
Firm Name and Address _______________________________
INSTRUCTIONS FOR FILLING OUT THIS FORM
What is the purpose of this form?
On September 27, 1999, the President of the United States granted certain Liberian nationals protection from removal from the United States until September 29, 2000. This is referred to as Deferred Enforced Departure (DED). The President also directed that these Liberians be granted employment authorization for the same time period. This is referred to as DED-related employment authorization.
This supplemental form allows Liberian nationals to apply for DED-related employment authorization. This form must be filed with Form I-765, Application for Employment Authorization, and the evidence and documentation listed below, if available. The Form I-765, item #16, should be filled in "(a)(11)" to indicate that you are filing for DED-related employment authorization.
Who is eligible for Liberian DED-related employment authorization?
With certain exceptions, the eligible class for Liberian DED-related employment authorization consists of Liberian nationals who are present in the United States as of September 29, 2001.
For Liberian DED-related employment authorization eligibility, "present" is defined to mean no absences from the United States after September 29, 2001, or if there were absences from the United States since that date: (1) the total time period of such absences does not exceed 180 days; AND (2) for each absence the Liberian national either returned to the United States with advance parole or was inspected and admitted to the United States.
What documentation should you file with this supplemental form?
You must submit two photographs meeting the specifications described in page four (4) of the instructions of the Form I-765, Application for Employment Authorization. Applicants must submit a copy of the documents requested below, if available. For purposes of simplification, this section includes the photographs and all relevant documents requested on pages two (2) and four (4) of Form I-765. You should only submit the requested materials once and not duplicate I-765 requirements.
• Form I-94, Arrival/Departure Record Your last Employment Authorization Document (EAD Card).
• Any documentation you may have which was issued by the Immigration and Naturalization Service (INS) evidencing that you were registered for TPS prior to September 29, 2001, or were in the United States as of September 29, 2001.
• If no EAD is available, submit any other photo identity document issued by a governmental entity. Prepare a copy with the clearest facial image possible. Examples include the photo page of your passport, your state driver's license or identity card, or school identification card.
• Any documentation you have to establish that you are a citizen or national of Liberia.
• If you cannot provide documentation, you may submit an affidavit affirming that you are a national of Liberia who was present in the United States as of September 29, 2001, and you are otherwise eligible for DED.
Every applicant must file his or her own I-765 application. All approved applicants will receive an employment authorization document (EAD) as proof of employment authorization.
Submission of copies of the documents may speed the processing of your application and may eliminate the need for a personal interview. (However the two (2) photographs must be submitted).
What effect will the receipt of a DED-based employment authorization document have on my immigration status?
Employment authorization is a benefit granted for a limited period of time to correspond with the authorized period of DED. It does not establish eligibility for permanent residence in the United States. [Note: An EAD is issued to a variety of qualifying aliens to evidence their authorization for employment. The EAD may also be used as evidence that INS has allowed the holder to remain in the United States for a specific period of time. Thus, an EAD may be issued to a person for whom employment is not a legal option, such as a minor child.]
What is the filing fee for the Form I-765 filed jointly with this supplemental form?
There is no fee for the Form I-765 file jointly with this form as part of the Liberian DED program. Applicants will need to submit a fifty ($50) dollar fingerprinting fee.
How should you prepare this form?
A. Type or print legibly in black or blue ink or ballpoint pen.
B. If you need extra space to complete any item, attach a continuation sheet, indicate the item number, and date and sign each sheet.
C. Answer all questions fully and accurately. If any item does not apply, please write "N/A."
Where should you file this form?
This form must be filed along with Form I-765 at the INS District Office or Suboffice having jurisdiction over the applicant's place of residence.
What are the penalties for perjury?
All statements contained in response to questions in this application are declared to be true and correct under penalty of perjury. Title 18 United States Code, Section 1546, provides in part:
...Whoever knowingly makes under oath, or as permitted under penalty of perjury under 1746 of Title 28 of the United States Code, knowingly subscribes as true, any false statement with respect to a material fact in any application, affidavit, or other document required by the immigration laws or regulations prescribed thereunder, or knowingly presents any such application, affidavit or other document containing any such false statement - shall be fined in accordance with this title or imprisoned not more than five years, or both.
What is the authority for collecting this information?
We request the information on the form to carry out the immigration laws contained in Title 8 of the United States Code, Section 1154(a). We need this information to determine whether you are eligible for immigration benefits. This information you provide may also be disclosed to other Federal, state, local and foreign law enforcement and regulatory agencies. Furnishing this information on this form is voluntary, however, if you do not give some or all of it, your application may be denied.
An agency may not conduct or sponsor an information collection and a person is not required to respond to an information collection unless it contains a currently valid OMB control number. We try to create forms that are accurate, can easily be understood, and which impose the least possible burden on you to provide us with the information. Often this is difficult because some immigration laws are very complex. Public reporting burden for this information collection is estimated to average 1 hour, computed as follows: 1) learning about the form, and understanding the instructions; 2) collecting the necessary supporting documents; 3) completing the form; and 4) traveling to and waiting at a preparer's office (for example, attorney or voluntary agency). If you have comments regarding the accuracy of this estimate or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, 425 I Street, N.W., Room 4304, Washington, DC 20536; OMB No. 1115-0220. DO NOT MAIL YOUR COMPLETED APPLICATION TO THIS ADDRESS.