Form I-566 Form I-566 Inter-Agency Record of Individual Requesting Change/Adju

OMB No. 1615-0027; Expires 02/28/09

I-566, Interagency Record of Request A, G, or NATO Dependent Employment Authorization
or Change/Adjustment to/from A, G, or NATO Status

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.

Part 1. Information About You ( The person seeking employment authorization or change/adjustment of status.)
1. Family Name

Given Name

Middle Name
Apt.#

2. Home Address - Street Number and Name
State

City
3. Mailing Address - Street Number and Name

Apt. #

4. Date of Birth (mm/dd/yyyy)
7. Gender
Male

5. Country of Birth

10. U.S. Social Security # (if any)

9. A # (if any)
Not Married

11. I-94 # (Arrival/Departure Document)

13. Date of Last Entry into the U.S. (mm/dd/yyyy)

Daytime Phone # (with area code)
6. Country of Citizenship

8. Marital Status
Married

Female

C/O (in care of):
Zip Code

State

City

Zip Code

14. Current Immigration Status

12. DOS Personal Identification # (PID)
15. Relationship to Principal (if applicable)

Part 2. Information About Principal Alien
1. Family Name

Given Name

Middle Name

2. Home Address - Street Number and Name

Apt.#

City

State

3. Date Tour of Duty Expected to End (mm/dd/yyyy)

4. Country of Citizenship

5. Marital Status

Zip Code

Married
6. Job Title

7. I-94 # (Arrival/Departure Document)

Not Married

8. DOS Personal Identification # (PID)

Part 3. Type of Request (See instructions for complete information on the different types of requests.)
1.

I am requesting employment authorization as a:
a.

2.

spouse.

b.

son or daughter, age:

, who:

is a full-time, post-secondary student.

is disabled.

I am requesting change/adjustment of status. (Select one.)
a.
Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to:
b.
Section 247(a), immigrant to A, or G nonimmigrant.
Change to other nonimmigrant status from A, G, or NATO - specifically to:
c.
d.
Adjustment from A, G, or NATO nonimmigrant to immigrant.
A-1, A-2, G-1, or G-2, nonimmigrant applying under Section 13 of the Act of September 11, 1957.
e.

Part 4. Certification Submit two copies with original signatures - "For official use only" page must also be attached
I certify under penalty of perjury that the foregoing is true and correct. I understand false information is a basis for denial or termination of the
benefit requested and for other penalties provided by law and regulation. If I am requesting employment authorization, I further certify that I do not
have a criminal record. I have not violated United States immigration and/or visa laws, I have not worked illegally in the United States, and I have
paid Social Security and all applicable taxes on all employment in the United States.

Signature

Date (mm/dd/yyyy)

Copy 1:USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE

Form I-566 (Rev. 02/28/08) N

Part 5. Your Personal Information
Your Name (family, given, middle)

Date of Birth (mm/dd/yyyy)

DOS Personal Identification # (PID)

For Official Use Only
Part 6. Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State (Certifying official must have this information and page to complete process.)
I certify that the information provided on the first page of this Form I-566 is true and correct to the best of my knowledge and
according to our official records.
As an applicant for employment authorization, I further certify that his or her eligibility has been verified under the provisions of:

A bilateral agreement with:

A de facto agreement with:

Check each of the following that apply:

Based on principal alien's G-4 status

Without a numerical limit

With a numerical limit and this applicant is within the limit; and
As an applicant for status as a principal alien, I further
and was notified to the DOS on (date):
certify that he or she is being offered the position of:
Signature of Certifying Officer or Official

Printed Name

Official Seal

Name and Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
Duty/Title

Phone Number (include area code)

Date (mm/dd/yyyy)

Part 7. DOS, NATO/HQ SACT, and/or USUN Use Only
1. The Department of State, NATO/HQ SACT, and/or USUN:
Recommends the request be granted
Recommends the request be denied
If the recommendation is for denial, provide a reason(s) for such recommendation:
2. Date (mm/dd/yyyy)

3. Phone Number (include area code)

4. Office:
Protocol
Signature 2

4. Signature 1

USUN

NATO/HQ SACT

Visa

Part 8. USCIS Use Only
1. From:
Adjudicator's Identification #

USCIS Office

Office Phone Number (with area code)

A # / File #

2. To:
Visa Office (Subject filed under Section 13. Please advise USCIS of your findings.)
USUN
Protocol
NATO/HQ SACT
If change of status granted, give new status:
Date of Decision (mm/dd/yyyy)
3. Adjustment or Change of Status:
Granted
Denied
4. Request for Employment Authorization: Date of Decision (mm/dd/yyyy):
Valid to (mm/dd/yyyy): Classification:
Denied
Granted
5. DOS/NATO/HQ SACT/USUN/Visa
Office Notified:
Yes
No

Date of Notification (mm/dd/yyyy):

Copy 1: USCIS Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE

Form I-566 (Rev. 02/28/08) N Page 2

OMB No. 1615-0027; Expires 02/28/09

I-566, Interagency Record of Request A, G, or NATO Dependent Employment Authorization
or Change/Adjustment to/from A, G, or NATO Status

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.

Part 1. Information About You (The person seeking employment authorization or change/adjustment of status.)
Given Name

1. Family Name

Middle Name
Apt.#

2. Home Address - Street Number and Name
State

City
3. Mailing Address - Street Number and Name

Apt. #
State

City
4. Date of Birth (mm/dd/yyyy)
7. Gender
Male

Zip Code
C/O (in care of):
Zip Code

5. Country of Birth

Female

10. U.S. Social Security # (if any)

Daytime Phone # (with area code)
6. Country of Citizenship

8. Marital Status
Not Married
Married

9. A # (if any)

11. I-94 # (Arrival/Departure Document)

12. DOS Personal Identification # (PID)

13. Date of Last Entry into the U.S. (mm/dd/yyyy)

14. Current Immigration Status

15. Relationship to Principal (if applicable)

Part 2. Information About Principal Alien
1. Family Name

Given Name

Middle Name

2. Home Address - Street Number and Name

Apt.#

City

State

3. Date Tour of Duty Expected to End (mm/dd/yyyy)

4. Country of Citizenship

5. Marital Status
Married

6. Job Title

7. I-94 # (Arrival/Departure Document)

Zip Code

Not Married

8. DOS Personal Identification # (PID)

Part 3. Type of Request (See instructions for complete information on the different types of requests.)
1.

I am requesting employment authorization as a:
a.

2.

spouse.

b.

son or daughter, age:

, who:

is a full-time, post-secondary student.

is disabled.

I am requesting change/adjustment of status. (Select one.)
a.
Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to:
b.
Section 247(a), immigrant to A, or G nonimmigrant.
c.
Change to other nonimmigrant status from A, G, or NATO - specifically to:
d.
Adjustment from A, G, or NATO nonimmigrant to immigrant.
A-1, A-2, G-1, or G-2 nonimmigrant applying under Section 13 of the Act of September 11, 1957.
e.

Part 4. Certification Submit two copies with original signatures - "For official use only" page must also be attached.
I certify under penalty of perjury that the foregoing is true and correct. I understand false information is a basis for denial or termination of the
benefit requested and for other penalties provided by law and regulation. If I am requesting employment authorization, I further certify that I do not
have a criminal record. I have not violated United States immigration and/or visa laws, I have not worked illegally in the United States, and I have
paid Social Security and all applicable taxes on all employment in the United States.

Date (mm/dd/yyyy)

Signature

Copy 1:USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE

Form I-566 (Rev. 02/28/08) N

Part 5. Your personal information
Your Name (family, given, middle)

Date of Birth (mm/dd/yyyy)

DOS Personal Identification # (PID)

For Official Use Only.
Part 6.

Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or NATO Member
State (Certifying official must have this information and page to complete process.)

I certify that the information provided on the first page of this Form I-566 is true and correct to the best of my knowledge and
according to our official records.
As an applicant for employment authorization, I further certify that his or her eligibility has been verified under the provisions of:

A bilateral agreement with:

A de facto agreement with:

Check each of the following that apply:

Without a numerical limit.

Based on principal alien's G-4 status
With a numerical limit and this applicant is within the limit; and
As an applicant for status as a principal alien, I further
and was notified to the DOS on (date):
certify that he or she is being offered the position of:
Signature of Certifying Officer or Official

Printed Name

Official Seal

Name and Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or
NATO Member State
Duty/Title

Part 7.

Phone Number (include area code)

Date (mm/dd/yyyy)

DOS, NATO/HQ SACT, and/or USUN Use Only

1. The Department of State, NATO/HQ SACT, and/or USUN:
Recommends the request be denied
Recommends the request be granted
If the recommendation is for denial, provide a reason(s) for such recommendation:
2. Date (mm/dd/yyyy)

3. Phone Number (include area code)

4. Office:
Protocol

NATO/HQ SACT

Visa

Signature 2

4. Signature 1

Part 8.

USUN

USCIS Use Only

1. From:
Adjudicator's Identification #

Office Phone Number (with area code)

USCIS Office

A-No. / File No.

2. To:
Protocol

USUN

NATO/HQ SACT

Visa Office (Subject filed under Section 13. Please advise USCIS of your findings.)

3. Adjustment or Change of Status:
Granted
Denied

Date of Decision (mm/dd/yyyy)

If change of status granted, give new status:

4. Request for Employment Authorization:

Date of Decision (mm/dd/yyyy):

Valid to (mm/dd/yyyy):

Denied
Granted
5. DOS/NATO/HQ SACT/USUN/Visa
Office Notified:

Date of Notification (mm/dd/yyyy):

Yes

Classification:

No

Copy 1: USCIS Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE

Form I-566 (Rev. 02/28/08) N Page 2