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 OMB No. 1615-0027
U.S. Citizenship and Immigration Services Expires 05/31/2018

FOR USCIS OFFICE ONLY

Remarks:

DRAFT
A-Number:

To be completed by an Select this box if Attorney State Bar Number Attorney or Accredited Representative
attorney or accredited Form G-28 is (if applicable) USCIS Online Account Number (if any)
representative (if any). attached.

► START HERE - Type or print in black ink.

NOT FOR
Accredited Representatives

Part 1. Information About You Other Information

NOTE: The person requesting employment authorization or 5. Date of Birth (mm/dd/yyyy)
change/adjustment of status provides the requested information.
6. Country of Birth
Full Legal Name

REPRODUCTION
1.a. Family Name 7. Country of Citizenship or Nationality
(Last Name)
1.b. Given Name
(First Name)
8. Gender Male Female
1.c. Middle Name
9. Marital Status

01/29/2018
Single Married Divorced Widowed
U.S. Mailing Address (USPS ZIP Code Lookup)
Legally Separated Marriage Annulled
2.a. In Care Of Name (if any)
Other

10. Alien Registration Number (A-Number) (if any)

2.b. Street Number
and Name ► A-
2.c. Apt. Ste. Flr. 11. U.S. Social Security Number (SSN) (if any)
►
2.d. City or Town
12. Department of State (DOS) Personal Identification
2.e. State 2.f. ZIP Code Number (PID)
3. Is your current mailing address the same as your physical
address? Yes No 13. USCIS Online Account Number (if any)
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
Information About Your Last Arrival in the
4.b. Apt. Ste. Flr. United States
4.c. City or Town 15.a. Form I-94 Arrival-Departure Record Number (if any)
►
4.d. State 4.e. ZIP Code

Form I-566 12/07/16 N Page 1 of 8

Part 1. Information About You (continued) 6. Marital Status
Single Married Divorced Widowed
15.b. Passport or Travel Document Number
Legally Separated Marriage Annulled
Other
15.c. Country That Issued Your Passport or Travel Document
7. DOS Personal Identification Number (PID)

DRAFT
15.d. Expiration Date for Your Passport or Travel Document
(mm/dd/yyyy) 8. USCIS Online Account Number (if any)
►
16. Date of Your Last Arrival into the United States, On or
About (mm/dd/yyyy)
Information About the Principal Alien's Last
17. Your Current Immigration Status (for example, A-3 Arrival in the United States

NOT FOR
attendant, G-1 principal representative, NATO-2 other
9.a. Form I-94 Arrival-Departure Record Number (if any)
representative)
►

9.b. Passport or Travel Document Number

Part 2. Information About Principal Alien

9.c. Country That Issued His or Her Passport or Travel
NOTE: If you are the principal alien and submitting Form

REPRODUCTION
Document
I-566 on your own behalf, do not complete this section.

Principal Alien's Full Legal Name 9.d. Expiration Date for His or Her Passport or Travel
Document (mm/dd/yyyy)
1.a. Family Name
(Last Name)
1.b. Given Name

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(First Name) Part 3. Type of Request
1.c. Middle Name 1. I am requesting (select only one box):
Employment Authorization
Principal Alien's U.S. Physical Address (Proceed to Item Numbers 2.a. - 2.d.)
2.a. Street Number Change/Adjustment of Status
and Name (Proceed to Item Numbers 3.a. - 3.b.)
2.b. Apt. Ste. Flr.
Requests for Employment Authorization
2.c. City or Town
2.a. I am a/an (select only one box):
2.d. State 2.e. ZIP Code Spouse Son or Daughter
Other Dependent Recognized by DOS
Principal Alien's Other Information
2.b. If you selected “Son or Daughter,” indicate your status if
3. Date Tour of Duty in the United States Expected to End you are 21 years of age or older (select only one box).
(mm/dd/yyyy)
Full-time, Post-secondary Student
4. Job Title Disabled Person
2.c. If you selected a status in Item Number 2.b., provide
your age.
5. Country of Citizenship or Nationality
2.d. If you selected “Other Dependent Recognized by DOS,”
provide your category below.

Form I-566 12/07/16 N Page 2 of 8

Part 3. Type of Request (continued) Requestor's Contact Information

Requests for Change/Adjustment of Status 3. Requestor's Daytime Telephone Number

3.a. I am requesting a/an (select only one box):

4. Requestor's Mobile Telephone Number (if any)
Change of Nonimmigrant Status TO A, G, or NATO
Change of Nonimmigrant Status FROM A, G, or

DRAFT
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
Adjustment of Status from A, G, or NATO
Copies of any documents I have submitted are exact
Nonimmigrant to Immigrant
photocopies of unaltered, original documents, and I understand

NOT FOR
Adjustment of Status Under 8 U.S.C. 1255b (Section that the U.S. Citizenship and Immigration Services (USCIS)
13 of the Act of September 11, 1957) from A-1, A-2, may require that I submit original documents to USCIS at a
G-1, or G-2 Nonimmigrant to Lawful Permanent later date. Furthermore, I authorize the release of any
Resident information from any and all of my records that USCIS may
3.b. If you selected “Change of Nonimmigrant Status” TO or need to determine my eligibility for the immigration benefit that
FROM “A, G, or NATO,” provide the specific category I seek.
below. I furthermore authorize release of information contained in this

REPRODUCTION
request, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the
NOTE: Form I-566 is not required if you have changed from
administration and enforcement of U.S. immigration law.
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
Part 4. Requestor's Statement, Contact

01/29/2018
information contained in, and submitted with, my request and
Information, Declaration, Certification, and that all of this information is complete, true, and correct.
Signature

NOTE: Read the Penalties section of the Form I-566

Requestor's Signature
Instructions before completing this section. 6.a. Requestor's Signature

Requestor's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If 6.b. Date of Signature (mm/dd/yyyy)
applicable, select the box for Item Number 2. NOTE TO ALL REQUESTOR'S: If you do not completely
1.a. I can read and understand English, and I have read fill out this request or fail to submit required documents listed
and understand every question and instruction on this in the Instructions, USCIS may deny your request.
request and my answer to every question.
8 CFR § 292.4 - Appearances.
CFR
1.b. The interpreter named in Part 5. read to me every prev | next
§ 292.4 Appearances.
question and instruction on this request and my (a) Authority to appear and act. An appearance must be filed on the appropriate form as prescribed by DHS by the
attorney or accredited representative appearing in each case. The form must be properly completed and signed by
answer to every question in the petitioner, applicant, or respondent to authorize representation in order for the appearance to be recognized by
DHS. The appearance will be recognized by the specific immigration component of DHS in which it was filed until
, the conclusion of the matter for which it was entered. This does not change the requirement that a new form must be
filed with an appeal filed with the Administrative Appeals Office of USCIS. Substitution may be permitted upon the
a language in which I am fluent, and I understood written withdrawal of the attorney or accredited representative of record or upon the filing of a new form by a new
attorney or accredited representative. When an appearance is made by a person acting in a representative capacity,
everything. his or her personal appearance or signature will constitute a representation that under the provisions of this chapter
he or she is authorized and qualified to appear as a representative as provided in 8 CFR 103.2(a)(3) and 292.1.
2. At my request, the preparer named in Part 6., Further proof of authority to act in a representative capacity may be required.

(b) A party to a proceeding and his or her attorney or representative will be permitted to examine the record of
, proceeding in accordance with 6 CFR part 5.

prepared this request for me based only upon [23 FR 2673, Apr. 23, 1958, as amended at 32 FR 9633, July 4, 1967; 52 FR 2941, Jan. 29, 1987; 59 FR 1466, Jan.
11, 1994; 75 FR 5230, Feb. 2, 2010; 76 FR 53797, Aug. 29, 2011]
information I provided or authorized.

Form I-566 12/07/16 N Page 3 of 8

Part 5. Interpreter's Contact Information, Interpreter's Certification
Certification, and Signature
I certify, under penalty or perjury, that:
Provide the following information about the interpreter.
I am fluent in English and , which
is the same language specified in Part 4., Item Number 1.b.,
Interpreter's Full Name and I have read to this requestor in the identified language every
1.a. Interpreter's Family Name (Last Name) question and instruction on this request and his or her answer to

DRAFT
every question. The requestor informed me that he or she
understands every instruction, question, and answer on the
1.b. Interpreter's Given Name (First Name) request, including the Requestor's Declaration and
Certification, and has verified the accuracy of every answer.

2. Interpreter's Business or Organization Name (if any) Interpreter's Signature

7.a. Interpreter's Signature

NOT FOR
Interpreter's Mailing Address
7.b. Date of Signature (mm/dd/yyyy)
3.a. Street Number
and Name
3.b. Apt. Ste. Flr. Part 6. Contact Information, Declaration, and

REPRODUCTION
3.c. City or Town
Signature of the Person Preparing this Request,
if Other Than the Requestor
3.d. State 3.e. ZIP Code
Provide the following information about the preparer.
3.f. Province
Preparer's Full Name
3.g. Postal Code

01/29/2018
1.a. Preparer's Family Name (Last Name)
3.h. Country

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

Interpreter's Contact Information

2. Preparer's Business or Organization Name (if any)
4. Interpreter's Daytime Telephone Number

5. Interpreter's Mobile Telephone Number (if any) Preparer's Mailing Address

3.a. Street Number
and Name
6. Interpreter's Email Address (if any)
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

Form I-566 12/07/16 N Page 4 of 8

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

DRAFT
5. Preparer's Mobile Telephone Number (if any)

6. Preparer's Email Address (if any)

NOT FOR
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

REPRODUCTION
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.

01/29/2018
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 N Page 5 of 8

Part 7. Additional Information 5.a. Page Number 5.b. Part Number 5.c. Item Number

If you need extra space to provide any additional information

within this request, use the space below. If you need more 5.d.
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,

DRAFT
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)
6.a. Page Number 6.b. Part Number 6.c. Item Number
1.c. Middle Name

NOT FOR
2. A-Number (if any) ► A- 6.d.
3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

REPRODUCTION
01/29/2018
7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

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 N Page 6 of 8

 FOR OFFICIAL USE ONLY Certifying Official's Signature

Part 8. Certification by Diplomatic Mission, 8.a. Certifying Official's Signature

International Organization, NATO/HQ SACT,
or NATO Member State
8.b. Date of Signature (mm/dd/yyyy)
NOTE: Certifying officer or official must have this
information and page to complete process.

DRAFT
Address of Diplomatic Mission, International
1. I certify that the information provided in Parts 1., 2., Organization, NATO/HQ SACT, or NATO Member
and 3. of this Form I-566 is true and correct to the best State
of my knowledge and according to our official records.
9.a. Name of Diplomatic Mission, International Organization,
2.a. I further certify that the requestor's eligibility for
NATO/HQ SACT, or NATO Member State
employment authorization was verified under the
provisions of a (select only one box):

NOT FOR
Bilateral Agreement 9.b. Street Number
and Name
Bilateral De facto Arrangement
9.c. Apt. Ste. Flr.
G-4 Regulations
9.d. City or Town
Additional Information About Agreement or Arrangement

REPRODUCTION
2.b. Name of the Country With Which the Agreement or 9.e. State 9.f. ZIP Code
Arrangement was Made
9.g. Province

2.c. Select all applicable boxes. 9.h. Postal Code

Without a Numerical Limit 9.i. Country

01/29/2018
With a Numerical Limit and This Requestor Is
Within the Limit
Official Seal
For Change/Adjustment of Status

3.a. I further certify that the principal alien is being

offered the following position:

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 N Page 7 of 8

 FOR OFFICIAL USE ONLY FOR OFFICIAL USE ONLY
Part 9. DOS, NATO/HQ SACT, and/or DOS Part 10. USCIS Information
USUN Information
Information About USCIS Immigration Services
1.a. Recommendation from DOS, NATO/HQ SACT, and/or Officer (ISO)
DOS USUN
Grant Request 1. ISO's Identification Number

DRAFT
Deny Request
2. USCIS Office
For Change/Adjustment of Status only:

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

3. Office Telephone Number (including area code)
the recommendation.

NOT FOR
2. Date of Recommendation (mm/dd/yyyy) Information About USCIS Action Taken on This
Request
3. Office Providing Recommendation 4. Where was USCIS decision sent?
DOS OFM DOS Protocol DOS Visa DOS OFM DOS Protocol DOS Visa
DOS USUN Host Country USUN NATO/HQ SACT DOS USUN Host Country

REPRODUCTION
NOTE: If the requestor filed under 8 U.S.C. 1255b
Signature and Contact Information for (“Section 13”), advise USCIS of findings.
Recommending Official
5.a. Decision for Change/Adjustment of Status
4.a. Recommending Official's Signature Granted Denied

01/29/2018
5.b. Date of Decision (mm/dd/yyyy)
4.b. Recommending Official's Daytime Telephone Number
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 N Page 8 of 8