Identification Numbers
Please provide the two identification numbers below.
Contact Information
Please provide your contact information.
I certify that:
- I was paroled into the United States under the Uniting for Ukraine process, or I am a Ukrainian national who was paroled into the United States between February 24, 2022 and September 30, 2023.
- I submitted Form I-765 to U.S. Citizenship and Immigration Services (USCIS) to apply for employment authorization between May 21, 2022 and November 21, 2022 based on my approved period of parole and paid a fee of $410 as indicated on my receipt number or identified through my A-number as provided in the form above.
- USCIS approved my Form I-765 and provided me with a USCIS Form I-766, Employment Authorization Document (EAD).
I hereby certify under penalty of perjury that the above information is true and correct, and agree to accept USCIS' offer to refund the $410 fee that was paid for processing my Form I-765.
USCIS Privacy Act Statement
AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the authorities of Immigration and Nationality Act sections 103, 212, and 274A.
PURPOSE: The primary purpose for providing the requested information on this form is for an individual to request a fee refund.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, will result in denial of your request.
ROUTINE USES: DHS may share the information you provide on this form and any additional requested evidence with other federal, state, local, and foreign government agencies, and authorized organizations. DHS follows approved routine uses described in the associated published system of records notice DHS/USCIS/ICE/CBP-001 - Alien File, Index which you can view at www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law enforcement purposes of in the interest of national security.
