Form I-566 Table of Changes

TABLE OF CHANGES – FORM

Form I-566, Interagency Record of Request – A, G, or NATO Dependent Employment Authorization or Change/Adjustment To/From A, G, or NATO Status

OMB Number: 1615-0027

05/24/2018

Reason for Revision: Limited revision with standard language, including formatting, plain language, and consistency edits.

Legend for Proposed Text:

• Black font = Current text

• Purple font = Standard language

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or accredited representative (if any).	[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)	[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)
Page 1, Part 1. Information About You	[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 Mailing Address 3.a. In Care Of Name 3.b. Street Number and Name 3.c. Apt./Ste./Flr. [Number] 3.d. City or Town 3.e. State 3.f. ZIP Code Physical Address 2.a. Street Number and Name 2.b. Apt./Ste./Flr. [Number] 2.c. City or Town 2.d. State 2.e. ZIP Code Other Information 4. Date of Birth (mm/dd/yyyy) 5. Country of Birth 6. Country of Citizenship or Nationality 7. Gender Male Female 8. Marital Status Single Married Divorced Widowed Legally Separated Marriage Annulled Other [Fillable field] 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) 19. Relationship to Principal (if applicable) 13. Form I-94 Arrival-Departure Record Number 14. Passport or Travel Document Number 15. Country of Issuance for Passport or Travel Document 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	[Page 1] Part 1. Information About You NOTE: The person requesting employment authorization or change/adjustment of status provides the requested information. Full Legal Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name U.S. Mailing Address 2.a. In Care Of Name (if any) 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Number] 2.d. City or Town 2.e. State 2.f. ZIP Code 3. 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. U.S. Physical Address 4.a. Street Number and Name 4.b. Apt./Ste./Flr. [Number] 4.c. City or Town 4.d. State 4.e. ZIP Code Other Information 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth 7. Country of Citizenship or Nationality 8. Gender Male Female 9. Marital Status Single Married Divorced Widowed Legally Separated Marriage Annulled Other [Fillable field] 10. Alien Registration Number (A-Number) (if any) 11. U.S. Social Security Number (SSN) (if any) 12. Department of State (DOS) Personal Identification Number (PID) 13. USCIS Online Account Number (if any) 14. Provide your relationship to the principal alien (if applicable). Information About Your Last Arrival into the United States 15.a. Form I-94 Arrival-Departure Record Number (if any) 15.b. Passport or Travel Document Number [Page 2] 15.c. Country That Issued Your Passport or Travel Document 15.d. Expiration Date for Your Passport or Travel Document (mm/dd/yyyy) 16. Date of Your Last Arrival into the United States, On or About (mm/dd/yyyy) 17. Your Current Immigration Status (for example, A-3 attendant, G-1 principal representative, NATO-2 other representative)
Page 2, Part 2. Information About Principal Alien	[Page 2] Part 2. Information About Principal Alien 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. [Number] 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) 6. Job Title 4. Country of Citizenship or Nationality 5. Marital Status Single Married Divorced Widowed Legally Separated Marriage Annulled Other [Fillable field] 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 12. Expiration Date for Passport or Travel Document (mm/dd/yyyy)	[Page 2] 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) 1.c. Middle Name Principal Alien’s U.S. Physical Address 2.a. Street Number and Name 2.b. Apt./Ste./Flr. [Number] 2.c. City or Town 2.d. State 2.e. ZIP Code Principal Alien’s Other Information 3. Date Tour of Duty in the United States Expected to End (mm/dd/yyyy) 4. Job Title 5. Country of Citizenship or Nationality 6. Marital Status Single Married Divorced Widowed Legally Separated Marriage Annulled Other [Fillable field] 7. DOS Personal Identification Number (PID) 8. USCIS Online Account Number (if any) 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 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)
Page 2, Part 3. Type of Request	[Page 2] Part 3. Type of Request 1. I am requesting employment authorization as (Select one): 1.a. Spouse [Son or daughter] [Other dependent recognized by the DOS] 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 [Fillable field] 2. I am requesting change/adjustment of status (Select one): 2.a. Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to [Fillable field] 2.c. Change to other nonimmigrant status from A, G, or NATO - specifically to [Fillable field] 2.b. Section 247(a), immigrant to A or G nonimmigrant. 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.	[Page 2] Part 3. Type of Request 1. I am requesting (select only one box): Employment Authorization (Proceed to Item Numbers 2.a. - 2.d.) Change/Adjustment of Status (Proceed to Item Numbers 3.a. - 3.b.) Requests for Employment Authorization 2.a. I am a/an (select only one box): Spouse Son or Daughter Other Dependent Recognized by DOS 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. [Fillable field] [Page 3] Requests for Change/Adjustment of Status 3.a. I am requesting a/an (select only one box): Change of Nonimmigrant Status TO A, G, or NATO Change of Nonimmigrant Status FROM A, G, or NATO Adjustment of Status Under Immigration and Nationality Act (INA) Section 247(a) from Immigrant to A or G Nonimmigrant 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. [Fillable field] NOTE: Form I-566 is not required if you have changed from A, G, or NATO nonimmigrant status to asylum (protected) status.
Page 2-3, Part 4. Requestor's Statement, Contact Information, Certification, and Signature	[Page 2] Part 4. Requestor's Statement, Contact Information, Certification, and Signature Read the Penalties section of the Form I-566 Instructions before completing this part. Requestor's Statement 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 [Fillable field], a language in which I am fluent, and I understood everything. [Page 3] 2. At my request, the preparer named in Part 6., [Fillable field], 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 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. 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.	[Page 3] Part 4. Requestor’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-566 Instructions before completing this section. Requestor’s Statement 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 [Fillable Field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 6., [Fillable field], 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 Declaration and Certification 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. 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. Requestor’s Signature 6.a. Requestor’s Signature 6.b. Date of Signature (mm/dd/yyyy) 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.
Page 3-4, Interpreter’s Contact Information, Certification, and Signature	[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. [Fillable field] 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 or perjury, that: I am fluent in English and [Fillable field], 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 4] Interpreter's Signature 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)	[Page 4] 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. [Fillable field] 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 Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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. Interpreter’s Signature 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 4, Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the Requestor	[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. [Fillable field] 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 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. 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 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)	[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. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country [Page 5] 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) 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)
Page 5, Part 7. Additional Information	[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) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 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] REQUESTORS - DO NOT PROCEED TO THE NEXT PAGE	[Page 6] 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) [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] NOTE TO ALL REQUESTORS: Do not complete Parts 8., 9., or 10. The agencies adjudicating your request will complete these sections.
Page 6, For Official Use Only Part 8. Certification by Diplomatic Mission, International Organization, NATO/HQ SACT, or NATO Member State	[Page 6] 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 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 [Fillable field] 2.b. A de facto agreement with [Fillable field] 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 7. Telephone Number (including area code) 6.a. Certifying Officer or Official's Signature 6.b. Date of Signature (mm/dd/yyyy) Address of Diplomatic Mission, International Organization, NATO/HQ SACT, or NATO Member State 8. Name 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	[Page 7] 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. 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 2.b. Name of the Country With Which the Agreement or Arrangement was Made 2.c. Select all applicable boxes. Without a Numerical Limit 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: [Fillable field] 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) 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 [Deleted] 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
Page 7, For Official Use Only Part 9. DOS OFM, DOS Visa Office, NATO/HQ SACT, and/or USUN USE ONLY	[Page 7] For Official Use Only Part 9. DOS OFM, DOS Visa Office, 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 the reasons for such a recommendation. [Fillable field] 2. Date of Decision (mm/dd/yyyy) 4. Office DOS Protocol USUN DOS OFM NATO/HQ SACT DOS Visa 5. Signature 1 3. Telephone Number (including area code) 6. Signature 2 [3. Telephone Number (including area code)]	[Page 8] 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 Deny Request For Change/Adjustment of Status only: 1.b. If you selected “Deny Request,” provide the reasons for the recommendation. [Fillable field] 2. Date of Recommendation (mm/dd/yyyy) 3. Office Providing Recommendation DOS OFM DOS Protocol DOS USUN Host Country DOS Visa USUN Signature and Contact Information for Recommending Official 4.a. Recommending Official's Signature 4.b. Recommending Official's Daytime Telephone Number
Page 7, For Official Use Only Part 10. USCIS USE ONLY	[Page 7] For Official Use Only Part 10. USCIS USE ONLY 1. From Adjudicator's ID Number USCIS Office Office Telephone Number (including area code) A-Number/File Number 2. To DOS Protocol USUN NATO/HQ SACT DOS OFM 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 [Fillable field] 4. Request for Employment Authorization Granted Denied Date of Decision (mm/dd/yyyy) Date Valid Until (mm/dd/yyyy) Classification 5. DOS OFM, USUN, NATO/HQ SACT, or DOS Visa Office Office Notified Yes No Date of Notification (mm/dd/yyyy)	[Page 8] FOR OFFICIAL USE ONLY Part 10. USCIS Information Information About USCIS Immigration Services Officer (ISO) 1. ISO’s Identification Number 2. USCIS Office 3. Office Telephone Number (including area code) Information About USCIS Action Taken on This Request 4. Where was USCIS decision sent? DOS OFM DOS Protocol DOS USUN Host Country DOS Visa NATO/HQ SACT NOTE: If the requestor filed under 8 U.S.C. 1255b (“Section 13”), advise USCIS of findings. [Page 9] 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. [Fillable field] 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)

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