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

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

FOR USCIS OFFICE ONLY
Remarks:

A-Number:
Select this box if
Form G-28 is
attached.

To be completed by an
attorney or accredited
representative (if any).

Attorney State Bar Number
(if applicable)

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

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► START HERE - Type or print in black ink.

Part 1. Information About You

Other Information

NOTE: The person requesting employment authorization or
change/adjustment of status provides the requested information.

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

7.

Country of Citizenship or Nationality

8.

Gender

9.

Marital Status

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

1.c. Middle Name

U.S. Mailing Address

Male

Single

(USPS ZIP Code Lookup)

Female

Married

Legally Separated

2.a. In Care Of Name (if any)

Divorced

Widowed

Marriage Annulled

Other

10.

2.b. Street Number
and Name
2.c.

Apt.

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

Ste.

Flr.

11.

U.S. Social Security Number (SSN) (if any)
►

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

2.f.

12.

Department of State (DOS) Personal Identification
Number (PID)

13.

USCIS Online Account Number (if any)

ZIP Code

Is your current mailing address the same as your physical
address?
Yes
No

NOTE: If you answered “No” to Item Number 3., provide
your physical address in Item Numbers 4.a. - 4.e.

►
14.

Provide your relationship to the principal alien
(if applicable).

U.S. Physical Address
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

15.a. Form I-94 Arrival-Departure Record Number (if any)

4.c. City or Town
4.d. State
Form I-566 12/07/16

Information About Your Last Arrival into the
United States
►

4.e. ZIP Code
Page 1 of 8

Part 1. Information About You (continued)

6.

Marital Status
Single

15.b. Passport or Travel Document Number

Married

Legally Separated

16.

17.

Date of Your Last Arrival into the United States, On or
About (mm/dd/yyyy)

Widowed

Marriage Annulled

Other

15.c. Country That Issued Your Passport or Travel Document

15.d. Expiration Date for Your Passport or Travel Document
(mm/dd/yyyy)

Divorced

7.

DOS Personal Identification Number (PID)

8.

USCIS Online Account Number (if any)
►

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Your Current Immigration Status (for example, A-3
attendant, G-1 principal representative, NATO-2 other
representative)

Information About the Principal Alien's Last
Arrival into the United States

9.a. Form I-94 Arrival-Departure Record Number (if any)
►

9.b. Passport or Travel Document Number

Part 2. Information About Principal Alien

NOTE: If you are the principal alien and submitting Form
I-566 on your own behalf, do not complete this section.

Principal Alien's Full Legal Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

9.c. Country That Issued His or Her Passport or Travel
Document

9.d. Expiration Date for His or Her Passport or Travel
Document (mm/dd/yyyy)

Part 3. Type of Request

1.c. Middle Name

1.

I am requesting (select only one box):

Principal Alien's U.S. Physical Address

Employment Authorization
(Proceed to Item Numbers 2.a. - 2.d.)

2.a. Street Number
and Name

Change/Adjustment of Status
(Proceed to Item Numbers 3.a. - 3.b.)

2.b.

Apt.

Ste.

Flr.

Requests for Employment Authorization

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

2.e. ZIP Code

2.a. I am a/an (select only one box):
Son or Daughter
Spouse

Other Dependent Recognized by DOS

Principal Alien's Other Information
3.

4.

5.

Date Tour of Duty in the United States Expected to End
(mm/dd/yyyy)
Job Title

Country of Citizenship or Nationality

2.b. If you selected “Son or Daughter,” indicate your status if
you are 21 years of age or older (select only one box).
Full-time, Post-secondary Student
Disabled Person
2.c. If you selected a status in Item Number 2.b., provide
your age.
2.d. If you selected “Other Dependent Recognized by DOS,”
provide your category below.

Form I-566 12/07/16

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Part 3. Type of Request (continued)

Requestor's Contact Information

Requests for Change/Adjustment of Status

3.

Requestor's Daytime Telephone Number

4.

Requestor's Mobile Telephone Number (if any)

Change of Nonimmigrant Status FROM A, G, or
NATO

5.

Requestor's Email Address (if any)

Adjustment of Status Under Immigration and
Nationality Act (INA) Section 247(a) from
Immigrant to A or G Nonimmigrant

Requestor's Declaration and Certification

3.a. I am requesting a/an (select only one box):
Change of Nonimmigrant Status TO A, G, or NATO

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Adjustment of Status from A, G, or NATO
Nonimmigrant to Immigrant

Adjustment of Status Under 8 U.S.C. 1255b (Section
13 of the Act of September 11, 1957) from A-1, A-2,
G-1, or G-2 Nonimmigrant to Lawful Permanent
Resident
3.b. If you selected “Change of Nonimmigrant Status” TO or
FROM “A, G, or NATO,” provide the specific category
below.

Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that the U.S. Citizenship and Immigration Services (USCIS)
may require that I submit original documents to USCIS at a
later date. Furthermore, I authorize the release of any
information from any and all of my records that USCIS may
need to determine my eligibility for the immigration benefit that
I seek.
I furthermore 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 law.

NOTE: Form I-566 is not required if you have changed from
A, G, or NATO nonimmigrant status to asylum (protected)
status.

I certify, under penalty of perjury, that all of the information in
my request and any document submitted with it were provided
or authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my request and
that all of this information is complete, true, and correct.

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

Requestor's Signature

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

6.a. Requestor's Signature

Requestor's Statement

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

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

NOTE TO ALL REQUESTOR'S: If you do not completely
fill out this request or fail to submit required documents listed
in the Instructions, USCIS may deny your request.

,
a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 6.,

,
prepared this request for me based only upon
information I provided or authorized.

Form I-566 12/07/16

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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 Certification
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 Declaration and
Certification, and has verified the accuracy of every answer.

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Interpreter's Business or Organization Name (if any)

Interpreter's Signature

7.a. Interpreter's Signature

Interpreter's Mailing Address

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

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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

Province

3.e. ZIP Code

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

3.g. Postal Code
3.h. Country

1.a. Preparer's Family Name (Last Name)

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

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

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.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-566 12/07/16

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Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Request,
if Other Than the Requestor (continued)
Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

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Preparer's Statement
7.a.

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

7.b.

I am an attorney or accredited representative and my
representation of the requestor in this case
extends
does not extend beyond the
preparation of this request.

NOTE: If you are an attorney or accredited representative, you
may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this
request.

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
Requestor's Declaration and 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)

Form I-566 12/07/16

Page 5 of 8

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. Type or print 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)
1.b. Given Name
(First Name)

5.b. Part Number

5.c. Item Number

5.d.

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6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

3.b. Part Number

6.d.

3.c. Item Number

7.a. Page Number

7.d.

4.a. Page Number

4.d.

4.b. Part Number

4.c. Item Number

NOTE TO ALL REQUESTORS: Do not complete
Parts 8., 9., or 10. The agencies adjudicating
your request will complete these sections.

Form I-566 12/07/16

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FOR OFFICIAL USE ONLY
Part 8. Certification by Diplomatic Mission,
International Organization, NATO/HQ SACT,
or NATO Member State
NOTE: Certifying officer or official must have this
information and page to complete process.
1.

I certify that the information provided in Parts 1., 2.,
and 3. of this Form I-566 is true and correct to the best
of my knowledge and according to our official records.

Certifying Official's Signature
8.a. Certifying Official's Signature

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

Address of Diplomatic Mission, International
Organization, NATO/HQ SACT, or NATO Member
State
9.a. Name of Diplomatic Mission, International Organization,
NATO/HQ SACT, or NATO Member State

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2.a. I further certify that the requestor's eligibility for
employment authorization was verified under the
provisions of a (select only one box):
Bilateral Agreement
Bilateral De facto Arrangement
G-4 Regulations

Additional Information About Agreement or Arrangement

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

Apt.

Ste.

Flr.

9.d. City or Town

2.b. Name of the Country With Which the Agreement or
Arrangement was Made

9.e. State

2.c. Select all applicable boxes.
Without a Numerical Limit

9.h. Postal Code

9.f.

ZIP Code

9.g. Province

9.i.

Country

With a Numerical Limit and This Requestor is
Within the Limit
For Change/Adjustment of Status
3.a.

I further certify that the principal alien is being
offered the following position:

Official Seal

3.b. DOS Notification Date (mm/dd/yyyy)

Certifying Official's Information
4.a. Certifying Official's Last Name

4.b. Certifying Official's First Name

5.

Certifying Official's Title

6.

Certifying Official's Daytime Telephone Number

7.

Certifying Official's Email Address (if any)

Form I-566 12/07/16

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FOR OFFICIAL USE ONLY

FOR OFFICIAL USE ONLY

Part 9. DOS, NATO/HQ SACT, and/or DOS
USUN Information
1.a. Recommendation from DOS, NATO/HQ SACT, and/or
DOS USUN
Grant Request

Part 10. USCIS Information
Information About USCIS Immigration Services
Officer (ISO)
1.

ISO's Identification Number

2.

USCIS Office

Deny Request
For Change/Adjustment of Status only:

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1.b. If you selected “Deny Request,” provide the reasons for
the recommendation.

3.

Office Telephone Number (including area code)

Information About USCIS Action Taken on This
Request

4.

2.

Date of Recommendation (mm/dd/yyyy)

Where was USCIS decision sent?
DOS OFM
DOS Protocol
NATO/HQ SACT

3.

Office Providing Recommendation
DOS OFM
DOS Protocol

DOS Visa

DOS USUN Host Country

Signature and Contact Information for
Recommending Official
4.a. Recommending Official's Signature

4.b. Recommending Official's Daytime Telephone Number

DOS Visa

DOS USUN Host Country

NOTE: If the requestor filed under 8 U.S.C. 1255b
(“Section 13”), advise USCIS of findings.

5.a. Decision for Change/Adjustment of Status
Granted

Denied

5.b. Date of Decision (mm/dd/yyyy)

5.c. If you selected “Granted,” provide the new status below.

6.a. Decision for Employment Authorization Request
Granted

Denied

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

6.c. Employment Authorization Valid Until (mm/dd/yyyy)

6.d. Classification

7.a. Were DOS, NATO/HQ SACT, and/or DOS USUN Host
Country notified?
Yes
No
7.b. Date of Notification (mm/dd/yyyy)

Form I-566 12/07/16

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