Form I-566 04/09/19 Page 1 of 8 Interagency Record of Request - A, G, or NATO Dependent Employment Authorization or Change/Adjustment To/From A, G, or NATO Status Department of Homeland Security U.S. Citizenship and Immigration Services A- 8.GenderMale Female 7. Country of Citizenship or NationalityMarital Status9.Alien Registration Number (A-Number) (if any)10. U.S. Social Security Number (SSN) (if any)11.Department of State (DOS) Personal Identification Number (PID)12. 13.USCIS Online Account Number (if any) OtherMarriage AnnulledLegally Separated Married SingleDivorced Widowed Other Information5.Date of Birth (mm/dd/yyyy) 6.Country of Birth Provide your relationship to the principal alien (if applicable). 14. 15.a. Form I-94 Arrival-Departure Record Number (if any) Information About Your Last Arrival into the United States 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) Part 1. Information About You Full Legal Name1.a.Family Name (Last Name) 1.b.Given Name (First Name) 1.c.Middle Name Street Number and Name2.b.2.d.City or Town2.e.State2.f.ZIP Code2.c. Ste. Flr. Apt. In Care Of Name (if any)2.a. U.S. Mailing AddressNOTE: The person requesting employment authorization or change/adjustment of status provides the requested information.3.Is your current mailing address the same as your physical address? Yes No U.S. Physical AddressStreet Number and Name4.a.4.c.City or Town4.d.State4.e.ZIP Code4.b. Ste. Flr. Apt. To be completed by an attorney or accredited representative (if any).USCIS Form I-566 OMB No. 1615-0027 Expires 04/30/2021START HERE - Type or print in black ink.A-Number: (USPS ZIP Code Lookup) FOR USCIS OFFICE ONLYRemarks: NOTE: If you answered 223No224 to Item Number 3., provide your physical address in Item Numbers 4.a. - 4.e. American LegalNet, Inc. www.FormsWorkFlow.com Form I-566 04/09/19 Page 2 of 8 17.Your Current Immigration Status (for example, A-3 attendant, G-1 principal representative, NATO-2 other representative) 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)15.c.Country That Issued Your Passport or Travel Document Part 1. Information About You (continued) Part 2. Information About Principal Alien Principal Alien's Full Legal Name1.a.Family Name (Last Name) 1.b.Given Name (First Name) 1.c.Middle Name Principal Alien's U.S. Physical AddressStreet Number and Name2.a.2.c.City or Town2.d.State2.e.ZIP Code2.b. Ste. Flr. Apt. NOTE: If you are the principal alien and submitting Form I-566 on your own behalf, do not complete this section. 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 Passport or Travel Document Number 15.b. 7.8. USCIS Online Account Number (if any) Information About the Principal Alien's Last Arrival into the United States9.a.Form I-94 Arrival-Departure Record Number (if any) Passport or Travel Document Number 9.b.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) DOS Personal Identification Number (PID) Part 3. Type of Request I am requesting (select only one box):1. 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 AuthorizationI am a/an (select only one box):2.a.Spouse Son or Daughter Other Dependent Recognized by DOS If you selected 223Son or Daughter,224 indicate your status if you are 21 years of age or older (select only one box).2.b.Disabled Person Full-time, Post-secondary Student 2.d.If you selected 223Other Dependent Recognized by DOS,224 provide your category below.If you selected a status in Item Number 2.b., provide your age.2.c.Marital Status6. OtherMarriage AnnulledLegally Separated Married SingleDivorced Widowed American LegalNet, Inc. www.FormsWorkFlow.com Form I-566 04/09/19 Page 3 of 8 Requests for Change/Adjustment of Status I am requesting a/an (select only one box):3.a.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 223Change of Nonimmigrant Status224 TO or FROM 223A, G, or NATO,224 provide the specific category below. NOTE: Form I-566 is not required if you have changed from A, G, or NATO nonimmigrant status to asylum (protected) status. Part 3. Type of Request (continued) Part 4.240 Requestor's Statement, Contact Information, Declaration, Certification, and SignatureNOTE: 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. Requestor's StatementNOTE: Read the Penalties section of the Form I-566 Instructions before completing this section. The interpreter named in Part 5. read to me every question and instruction on this request and my answer to every question in1.b. 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. Requestor's Contact InformationRequestor's Email Address (if any) 4.Requestor's Daytime Telephone Number3. Requestor's Mobile Telephone Number (if any)5. 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. Requestor's Declaration and CertificationI 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 Signature6.a.6.b.Date of Signature (mm/dd/yyyy) Requestor's SignatureNOTE 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. American LegalNet, Inc. www.FormsWorkFlow.com Form I-566 04/09/19 Page 4 of 8 Interpreter's CertificationI certify, under penalty or perjury, that: 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. I am fluent in English and , Interpreter's SignatureInterpreter's Signature 7.a.7.b.Date of Signature (mm/dd/yyyy) Part 6.240 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 Name1.a. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)1.b. Preparer's Business or Organization Name (if any)2. Preparer's Mailing Address3.c.City or Tow