Current
Page and Section
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Current
Text
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Proposed
Text
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New
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[Page
1]
To
be completed by an attorney or accredited representative (if
any).
Select
this box if Form G-28 is attached.
Attorney
State Bar Number (if
applicable)
Attorney
or Accredited Representative USCIS Online Account Number (if
any)
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Page
1,
Part
1. Information About You (The
person seeking employment authorization or change/adjustment of
status.)
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Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Home
Address
Street
Number and Name
Apt.
Number
City
State
Zip
Code
Mailing
Address
Street
Number and Name
Apt.
Number
City
State
Zip
Code
Daytime
Phone Number (with
area code)
Date
of Birth (mm/dd/yyyy)
Country
of Birth
Country
of Citizenship
Gender
Male/Female
Marital
Status
Married/Not
Married
A-Number
(if
any)
U.S.
Social Security Number (if
any)
DOS
Personal Identification Number (PID)
I-94
Number (Arrival-Departure
Document)
Passport
or Travel Document Number
Country
of Issuance for Passport or Travel Document Number
Expiration
Date for Passport or Travel Document (mm/dd/yyyy)
Date
of Last Entry into United States (mm/dd/yyyy)
Current
Immigration Status
Relationship
to Principal (if
applicable)
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[Page
1]
Part
1. Information About You (The
person seeking employment authorization or change/adjustment of
status.)
Full
Name
1.a.
Family
Name (Last Name)
1.b.
Given
Name (First Name)
1.c.
Middle
Name
Physical
Address
2.a.
Street
Number and Name
2.b.
Apt.
Ste. Flr. [Fillable Field]
2.c.
City
or
Town
2.d.
State
2.e.
ZIP
Code
Mailing
Address
3.a.
In Care Of Name
3.b.
Street
Number and Name
3.c.
Apt.
Ste. Flr. [Fillable Field]
3.d.
City
or
Town
3.e.
State
3.f.
ZIP
Code
[Deleted]
Other
Information
4.
Date
of Birth (mm/dd/yyyy)
5.
Country
of Birth
6.
Citizenship
or Nationality
7.
Gender
Male/Female
8.
Marital
Status
Single/Married/Divorced/Widowed/Legally
Separated/Marriage Annulled/Other
9.
Alien
Registration Number (A-Number)
(if any)
10.
U.S.
Social Security Number (if
any)
11.
DOS
Personal Identification Number (PID)
12.
USCIS
Online Account Number (if any)
13.
Form
I-94
Arrival-Departure
Record Number
14.
Passport
or Travel Document Number
15.
Country
of Issuance for Passport or Travel Document Number
16.
Expiration
Date for Passport or Travel Document (mm/dd/yyyy)
17.
Date
of Last Entry into United States (mm/dd/yyyy)
18.
Current
Immigration Status
19.
Relationship
to Principal (if applicable)
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Page
1.,
Part
2. Information About Principal Alien
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Family
Name (Last Name0
Given
Name (First Name0
Middle
Name
Home
Address
Street
Number and Name
Apt.
Number
City
State
Zip
Code
Date
Tour of Duty Expected to End (mm/dd/yyyy)
Country
of Citizenship
Marital
Status
Married/Not
Married
Job
Title
DOS
Personal Identification Number (PID)
I-94
Number (Arrival-Departure
Document)
Passport
or Travel Document Number
Country
of Issuance for Passport or Travel Document Number
Expiration
Date for Passport or Travel Document (mm/dd/yyyy)
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[Page
1]
Part
2. Information About Principal Alien
Full
Name
1.a.
Family Name (Last Name0
1.b.
Given Name (First Name0
1.c.
Middle Name
Physical
Address
2.a.
Street Number and Name
2.b.
Apt. Ste. Flr.
2.c.
City or Town
2.d.
State
2.e.
ZIP Code
Other
Information
3.
Date Tour of Duty Expected to End (mm/dd/yyyy)
4.
Citizenship or Nationality
5.
Marital
Status
Single/Married/Divorced/Widowed/Legally
Separated/Marriage Annulled/Other
6.
Job Title
7.
DOS Personal Identification Number (PID)
8.
USCIS Online Account Number (if any)
9.
Form I-94 Arrival-Departure Record Number
10.
Passport or Travel Document Number
11.
Country of Issuance for Passport or Travel Document Number
12.
Expiration Date for Passport or Travel Document (mm/dd/yyyy)
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Page
2,
Part
3. Type of Request
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I
am requesting employment authorization as (select one):
spouse
son
or daughter, age: who:
is
a full-time, post-secondary student
is
disabled
other
dependent recognized by the DOS:_
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.
e.A-1,
A-2, G-1, or G-2, nonimmigrant applying under Section 13 of the
Act of September 11, 1957.
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[Page
2]
Part
3. Type of Request
1.
I
am requesting employment authorization as (Select one):
1.a.
Spouse
1.b.
Son
or daughter, age [Fillable Field], who
is:
A
full-time, post-secondary student
Disabled
1.c.
Other
dependent recognized by the DOS
2.
I
am requesting change/adjustment of status (Select one):
2.a.
Change
of nonimmigrant status to A, G, or NATO nonimmigrant- specifically
to
2.b.
Section
247(a), immigrant to A or G nonimmigrant.
2.c.
Change
to other nonimmigrant status from A, G, or NATO- specifically to
2.d.
Adjustment
from A, G, or NATO nonimmigrant to immigrant.
2.e.
A-1,
A-2, G-1, or G-2 nonimmigrant applying under Section 13 of the Act
of September 11, 1957.
NOTE:
This
request is not required if you have changed from an A or G
nonimmigrant to Asylum (protection) status.
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Page
2,
Certification
(Submit
two copies with original signatures.)
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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
of Applicant
Date
(mm/dd/yyyy)
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[Page
2]
Part
4. Requestor’s Statement, Contact Information,
Certification, and Signature
NOTE:
Read
the Penalties
section of
the
Form I-566 Instructions
before
completing
this part.
NOTE:
Select the box for either Item
Number 1.a. or 1.b.
If applicable, select the box for Item
Number 2.
1.a.
I can read and understand English, and I
have read and understand every question and instruction on this
request
and
my
answer to every question.
1.b.
The interpreter named in Part
5.
read to me every
question and instruction on this request
and
my answer to every question in ________________________, a
language in which I am fluent,
and I understood everything.
[Page
3]
2.
At
my request, the preparer named in
Part
6.,
_________________________, prepared this request
for me
based only upon information I provided or authorized.
Requestor’s
Contact Information
3.
Requestor’s
Daytime
Telephone Number
4.
Requestor’s
Mobile
Telephone Number (if any)
5.
Requestor’s
Email
Address (if any)
Requestor’s
Certification
Copies
of any documents I have submitted are exact photocopies of
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore,
I authorize the release of any information from any
of
my
records that USCIS may need to determine my eligibility for the
immigration benefit I seek.
I
further
authorize
release of information contained in this request, in supporting
documents, and in my USCIS records, to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration laws.
I
certify,
under
penalty
of perjury, that I
provided or authorized
all
of the information in my application, I
understand all of the information contained in, and submitted with
my
application, and
that all of this information is
complete, true, and correct.
Requestor’s
Signature
6.a.
Requestor’s
Signature
6.b.
Date
of
Signature (mm/dd/yyyy)
NOTE
TO ALL REQUESTORS: If
you do not completely fill out this request or fail to submit
required documents listed in the Instructions, USCIS may deny your
request.
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Page
2,
Part
5. Your Personal Information
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Name
of Applicant (Family,
Given, Middle)
Date
of Birth (mm/dd/yyyy)
DOS
Personal Identification Number (PID)
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[Deleted]
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New
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[Page
3]
Part
5. Interpreter’s Contact Information, Certification, and
Signature
Provide
the following information about the interpreter.
Interpreter’s
Full Name
1.a.
Interpreter's
Family Name (Last Name)
1.b.
Interpreter's
Given Name (First Name)
2.
Interpreter's
Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.a.
Street
Number and Name
3.b.
Apt.
Ste. Flr.
3.c.
City
or Town
3.d.
State
3.e.
ZIP
Code
3.f.
Province
3.g.
Postal
Code
3.h.
Country
Interpreter’s
Contact Information
4.
Interpreter's
Daytime Telephone Number
5.
Interpreter’s
Email Address (if any)
Interpreter’s
Certification
I
certify,
under penalty of perjury,
that:
I
am fluent in English and ____________,
which
is the same language specified
in
Part
4.,
Item
Number
1.b.,
and
I
have read to this requestor in
the identified language
every question and instruction on this request and
his or her
answer to every question.
The
requestor informed
me that he or she understands every instruction,
question, and answer
on the request, including
the Applicant's
Certification,
and has
verified the accuracy of every answer.
[Page
4]
Interpreter’s
Signature
6.a.
Interpreter's Signature
6.b.
Date of Signature (mm/dd/yyyy)
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New
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NOTE:
Certifying
official must have this information and page to complete process.
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[Page
4]
Part
6. Contact Information, Declaration,
and Signature of the Person Preparing this Request, if Other Than
the Requestor
Provide
the following information about the preparer.
Preparer’s
Full Name
1.a.
Preparer’s Family Name (Last Name)
1.b.
Preparer’s Given Name (First Name)
2.
Preparer’s Business or Organization Name (if any)
Preparer’s
Mailing Address
3.a.
Street Number and Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
3.h.
Country
Preparer’s
Contact Information
4.
Preparer’s Daytime Telephone Number
5.
Preparer’s Fax Number (if any)
6.
Preparer’s Email Address (if any)
Preparer’s
Statement
7.a.
I am not an attorney or accredited representative but have
prepared this form
on
behalf of the authorized
individual
and
with the authorized
individual’s
consent.
7.b.
I am an attorney or accredited representative and have
prepared this form on behalf of the authorized individual and with
the authorized individual’s consent.
Preparer’s
Certification
By
my signature, I certify,
under penalty
of
perjury, that I prepared this request
at
the
request
of the requestor. The
requestor
then
reviewed this completed
request
and
informed me that he or she understands all of the information
contained in, and submitted with, his or her
request,
including
the Applicant’s
Certification,
and that all of this information is complete, true, and correct.
I completed this
request
based
only on information that the
requestor
provided
to me or authorized me to obtain or use.
Preparer’s
Signature
8.a.
Preparer's Signature
8.b.
Date of Signature (mm/dd/yyyy)
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New
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[Page
5]
Part
7. Additional Information
If
you need extra space to provide any additional information within
this request,
use the space below. If you need more space than what is
provided, you may make copies of this page to complete and file
with this request
or
attach a separate sheet of paper. Include your name and A-Number
(if any) at the top of each sheet; indicate the Page
Number,
Part
Number,
and Item
Number
to which your answer refers; and sign and date each sheet.
1.a.
Family Name (Last Name) [Auto-populated field]
1.b.
Given Name (First Name) [Auto-populated field]
1.c.
Middle Name [Auto-populated field]
2.
A-Number (if any) [Auto-populated field]
3.a.
Page Number
3.b.
Part Number
3.c.
Item Number
3.d.
[Fillable Field]
4.a.
Page Number
4.b.
Part Number
4.c.
Item Number
4.d.
[Fillable Field]
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
[Fillable Field]
6.a.
Page Number
6.b.
Part Number
6.c.
Item Number
6.d.
[Fillable Field]
7.a.
Page Number
7.b.
Part Number
7.c.
Item Number
7.d.
[Fillable Field]
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Page
2.,
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.)
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[Page
2[
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.
I
further certify that the applicant's eligibility for employment
authorization has been verified under the provisions of:
A
bilateral agreement with:
A
de
facto
agreement with:
Check
all 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
I
further certify that the applicant for status as a principal alien
is being offered the position below and DOS was notified.
Position:
DOS
Notification Date:
Printed
Name Certifying Officer or Official
Duty/Title
Signature
of Certifying Officer or Official
Date
(mm/dd/yyyy)
Phone
Number
(include area code)
Name
and Address of Diplomatic Mission, International Organization,
NATO/HQ SACT, or NATO Member State
Official
Seal
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[Page
6]
For
Official Use Only
Part
8.
Certification
by Diplomatic Mission, International Organization, NATO/HQ SACT,
or NATO Member State
NOTE:
Certifying
official must have this information and page to complete process.
1.
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.
2.
I
further certify that the requestor’s
eligibility
for employment authorization was
verified
under the provisions of:
2.a.
A
bilateral agreement with
2.b.
A
de
facto
agreement with
2.c.
Select
all that apply
Without
a numerical limit
Based
on principal alien’s G-4 status
With
a numerical limit and this requestor is within the limit
3.
I
further certify that the requestor
for
status as a principal alien is being offered the position below
and DOS was notified
Position
DOS
Notification Date (mm/dd/yyyy)
4.a.
Certifying
Officer or Official’s Last
Name
4.b.
Certifying
Officer or Official’s First
Name
5.
Certifying
Officer or Official’s Duty/Title
6.a.
Certifying
Officer or Official’s Signature
6.b.
Date
of Signature
(mm/dd/yyyy)
7.
Telephone
Number
(including
area
code)
8.
Name
of Diplomatic
Mission, International Organization, NATO/HQ SACT, or NATO Member
State
Address
of Diplomatic
Mission, International Organization, NATO/HQ SACT, or NATO Member
State
9.a.
In
Care Of Name
9.b.
Street
Number and Name
9.c.
Apt.
Ste. Flr. [Fillable Field]
9.d.
City
or Town
9.e.
State
9.f.
ZIP
Code
9.g.
Province
9.h.
Postal
Code
9.i.
Country
Official
Seal
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Page
7,
For
Official Use Only
Part
9. DOS, NATO/HQ SACT, and or USUN Use Only
The
Department of State, NAT/HQ SACT, and/or USUN
Recommends
the request be granted
Recommends
the request be denied
If
the recommendation is for denial, provide a reasons for such a
recommendation
Date
of
Decision (mm/dd/yyyy)
Telephone
Number (include area code)
Office
Protocol
USUN
NATO/HQ
SACT
Visa
Signature
1
Signature
2
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|
USCIS
Use Only
From:
Adjudicator
ID Number
USCIS
Office
Office
Telephone Number
Alien
Registration Number
To:
Protocol
USUN
NATO/HQ
SACT
Visa
Office (Subject filed under Section 13. Advise USCIS of
findings.)
Adjustment
or Change of Status
Granted
Date of Decision (mm/dd/yyyy)
If
change of status granted, write new status:_
Denied
Date of Decision (mm/dd/yyyy)
If
change of status granted, write new status
Request
for Employment Authorization:
Granted
Denied
Date
of Decision (mm/dd/yyyy)
Valid
to(mm/dd/yyy)
Classification
DOS,
USUN, NATO/HQ SACT, OR Visa Office
Office
Notified: Yes
No
Date
of Notification (mm/dd/yyyy)
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Page
7,
Part
10. USCIS USE ONLY
From
Adjudicator
ID Number
USCIS
Office
Office
Telephone Number (with area code)
A-Number/File
Number
To
Protocol
USUN
NATO/HQ
SACT
Visa
Office (Subject filed under Section 13. Advise USCIS of
findings.)
Adjustment
or Change of Status
Granted
Denied
Date
of Decision (mm/dd/yyyy)
If
change of status granted, print
new
status
Request
for Employment Authorization:
Granted
Denied
Date
of Decision (mm/dd/yyyy)
Date
Valid Until
(mm/dd/yyy)
Classification
DOS,
USUN, NATO/HQ SACT, OR Visa Office
Office
Notified Yes
No
Date
of Notification (mm/dd/yyyy)
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