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

Interagency Record of Request A, G, or NATO Dependent Employment Authorization or
Change/Adjustment To/From A, G, or NATO Status

USCIS
Form I-566

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

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)

OMB No. 1615-0027
Expires 05/31/2018

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

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

6.

Country of Citizenship or Nationality

7.

Gender

Full Name

8.

Marital Status
Single

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Male

Female

Married

Widowed

Legally Separated

Marriage Annulled

1.c. Middle Name

9.

Divorced

Other

Alien Registration Number (A-Number) (if any)
► A-

Physical Address

10.

U.S. Social Security Number (if any)

2.a. Street Number
and Name
2.b.

Apt.

►

Ste.

Flr.

2.c. City or Town
2.d. State

11.

DOS Personal Identification Number (PID)

12.

USCIS Online Account Number (if any)
►

2.e. ZIP Code
13.

Form I-94 Arrival-Departure Record Number

Mailing Address

►

3.a. In Care Of Name

3.b. Street Number
and Name
3.c.

Apt.

Ste.

14.

Passport or Travel Document Number

15.

Country of Issuance for Passport or Travel Document

16.

Expiration Date for Passport or Travel Document

Flr.

3.d. City or Town
3.e. State

(mm/dd/yyyy)
3.f.

ZIP Code

Other Information
4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

Form I-566 05/10/16 N

17.

Date of Last Entry into United States (mm/dd/yyyy)

18.

Current Immigration Status

19.

Relationship to Principal (if applicable)

Page 1 of 7

Part 2. Information About Principal Alien

Part 3. Type of Request

Full Name

1.

I am requesting employment authorization as
(Select one):

1.a.

Spouse

1.b.

Son or daughter, age

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

, who is:

A full-time, post-secondary student

1.c. Middle Name

Disabled

Physical Address
2.a. Street Number
and Name
2.b.

Apt.

Ste.

Flr.

2.c. City or Town
2.d. State

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.

2.e. ZIP Code

Other Information
3.

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

4.

Country of Citizenship or Nationality

5.

Marital Status
Single

Married

Widowed

Divorced

Legally Separated

Marriage Annulled

NOTE: This request is not required if you have changed from
an A or G nonimmigrant to Asylum (protection) status.

Other

6.

Job Title

Part 4. Requestor's Statement, Contact
Information, Certification, and Signature

7.

DOS Personal Identification Number (PID)

Read the Penalties section of the Form I-566 Instructions
before completing this part.

8.

USCIS Online Account Number (if any)

Requestor's Statement

►
9.

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.

Form I-94 Arrival-Departure Record Number
►

10.

11.

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

Passport or Travel Document Number

Country of Issuance for Passport or Travel Document

,
12.

Expiration Date for Passport or Travel Document

a language in which I am fluent, and I understood
everything.

(mm/dd/yyyy)

Form I-566 05/10/16 N

Page 2 of 7

Part 5. Interpreter's Contact Information,
Certification, and Signature

Part 4. Requestor's Statement, Contact
Information, Certification, and Signature
(continued)
2.

Provide the following information about the interpreter.

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.

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

Requestor's Daytime Telephone Number
2.

4.

Requestor's Mobile Telephone Number (if any)

5.

Requestor's Email Address (if any)

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

Requestor's Certification
3.c. City or Town
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 request, I understand all of the
information contained in, and submitted with my request, and
that all of this information is complete, true, and correct.

3.d. State
3.f.

3.e. ZIP Code

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)

Requestor's Signature
6.a. Requestor's Signature

Interpreter's Certification
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.

Form I-566 05/10/16 N

I certify, under penalty or 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 Requestor's Certification, and has
verified the accuracy of every answer.

Page 3 of 7

Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.a. Interpreter's Signature

5.

Preparer's Fax Number (if any)

6.b. Date of Signature (mm/dd/yyyy)

6.

Preparer's Email Address (if any)

Interpreter's Signature

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor

Preparer's Statement
7.a.

I am not an attorney or accredited representative but
have prepared this request 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 request on behalf of the authorized
individual and with the authorized individual's
consent.

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)

Preparer's Certification
2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

Preparer's Signature

3.c. City or Town
3.d. State
3.f.

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
Requestor'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.

3.e. ZIP Code

8.a. Preparer's Signature

Province
8.b. Date of Signature (mm/dd/yyyy)

3.g. Postal Code
3.h. Country

Form I-566 05/10/16 N

Page 4 of 7

5.a. Page Number

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.

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

6.a. Page Number

A-Number (if any) ► A6.d.

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.

7.a. Page Number

7.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

Form I-566 05/10/16 N

REQUESTORS - DO NOT PROCEED TO THE NEXT PAGE

Page 5 of 7

For Official Use Only
Part 8. Certification by Diplomatic Mission,
International Organization, NATO/HQ SACT,
or NATO Member State

8.

NOTE: Certifying officer or official must have this
information and page to complete process.

Address of Diplomatic Mission, International Organization,
NATO/HQ SACT, or NATO Member State

1.

9.a. In Care Of Name

2.

2.a.

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 requestor's eligibility for
employment authorization was verified under the
provisions of:
A bilateral agreement with

Name of Diplomatic Mission, International Organization,
NATO/HQ SACT, or NATO Member State

9.b. Street Number
and Name
9.c.

Apt.

A de facto agreement with

2.c. Select all that apply
Without a numerical limit

Flr.

9.d. City or Town
9.e. State

2.b.

Ste.

9.f.

ZIP Code

9.g. Province
9.h. Postal Code
9.i.

Country

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
Official Seal
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)

Form I-566 05/10/16 N

Page 6 of 7

For Official Use Only
Part 9. DOS OFM, DOS Visa Office, NATO/HQ
SACT, and/or USUN USE ONLY
1.

Part 10. USCIS USE ONLY
1.

The Department of State, NATO/HQ SACT, and/or USUN

From
Adjudicator's ID Number

Recommends the request be granted
Recommends the request be denied

USCIS Office

If the recommendation is for denial, provide the
reasons for such a recommendation.
Office Telephone Number (including area code)

A-Number/File Number

2.

To

DOS Protocol

USUN

DOS OFM

NATO/HQ SACT
DOS Visa Office (Subject filed under Section
13. Advise USCIS of findings.)
3.

Adjustment or Change of Status
Granted

Denied

Date of Decision (mm/dd/yyyy)
If change of status granted, print new status

4.

Request for Employment Authorization
Granted

Denied

Date of Decision (mm/dd/yyyy)
Date Valid Until (mm/dd/yyyy)
Classification
2.

Date of Decision (mm/dd/yyyy)

3.

Telephone Number (including area code)

5.

DOS OFM, USUN, NATO/HQ SACT, or DOS Visa
Office
Office Notified

4.

Yes

No

Office
DOS Protocol
NATO/HQ SACT

5.

Signature 1

6.

Signature 2

Form I-566 05/10/16 N

USUN

DOS OFM

Date of Notification (mm/dd/yyyy)

DOS Visa

Page 7 of 7