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SCORE-Bench

Dataset card Data Studio Files
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Street Name and Number City Province or State ZIP Code/ Postal Code Country From Month Year To Month Year
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Applicant's employment last five years. (If none, type or print "none.") List present employment first.
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Full Name and Address of Employer Occupation (Specify) From Month Year To Month Year
Present Time
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Last occupation abroad if not shown above. (Include all information requested above.)
This form is submitted for:
[x] Deferred Action Request
Signature of Applicant
Date (mm/dd/yyyy)
⮕
If your native alphabet is in other than Roman letters, write your name in your native alphabet below:
___
Penalties: Severe penalties are provided by law for knowingly and willfully falsifying or concealing a material fact.
Applicant: Print your name and Alien Registration Number in the box outlined by heavy border below.
Complete This Box (Family Name) (Given Name) (Middle Name) (Alien Registration Number) A
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Form G-325A (Rev. 10/25/23)
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Part 3. Employment Authorization (continued)
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If “Yes,” please provide the following information regarding your economic necessity for employment (this information is not required if you are requesting the SIJ DA filing type):
2.a. My current annual income is:
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$46,000
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2.b. My current annual expenses are:
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$79,000
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2.c. The total current value of my assets is:
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$2,450
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2.d. If you would like to provide an explanation regarding your current financial information or your economic need for employment authorization, please use this space below. If you need extra space to complete this section, use the space provided in Part 8. Additional Information.
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SURVIVOR’S BENEFIT IS NO LONGER ENOUGH TO COVER LIVING EXPENSES DUE TO MEDICAL CRISIS. CANNOT SELL ONE ASSET (CAR) SINCE NEEDED FOR TRANSPORT FOR DR APPTS.
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Part 4. Social Security Card
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If you select “Yes” on Part 3. Employment Authorization, Item Number 1., please complete the following questions to receive a Social Security card through this process. If the below questions and questions in Part 1. are not completed, you will not receive a Social Security card through this process.
1. Do you want the Social Security Administration (SSA) to issue you an original or replacement Social Security card?
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[x]
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Yes (Complete Item Numbers 2. - 3.)
[] No (Go to Part 5.)
2. Provide your Social Security Number (SSN) (if any).
▶ _________
3. Consent for Disclosure: I authorize disclosure of information from this application and USCIS systems to the SSA as required for the purpose of assigning me an SSN and issuing me an original or replacement Social Security card.
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[x]
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Yes [] No
NOTE: If you answered “Yes” to Item Number 1., you must also answer “Yes” to Item Number 3., Consent for Disclosure, to receive a card.
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Part 5. Requestor's Contact Information, Certification, and Signature
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Requestor's Contact Information
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Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1. Requestor’s Daytime Telephone Number
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330-862-2911
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2.
Requestor's Mobile Telephone Number (if any)