Form I-566 - Interagency Record Of Request

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OMB No. 1615-0027
I-566, Interagency Record of Request
Department of Homeland Security
A, G, or NATO Dependent Employment Authorization
U.S. Citizenship and Immigration Services
or Change/Adjustment To/From A, G, or NATO Status
START HERE - Type or print in black ink.
Part 1. Information About You
(The person seeking employment authorization or change/adjustment of status.)
1. Family Name
Given Name
Middle Name
Apt. #
2. Home Address - Street Number and Name
City
State
Zip Code
3. Mailing Address - Street Number and Name
Apt. #
C/O (in care of):
City
State
Zip Code
Daytime Phone # (with area code)
4. Date of Birth (mm/dd/yyyy)
5. Country of Birth
6. Country of Citizenship
9. A-Number (if any)
7. Gender
8. Marital Status
Male
Female
Married
Not Married
10. U.S. Social Security # (if any)
11. I-94 # (Arrival-Departure Document)
12. DOS Personal Identification # (PID)
13. Date of Last Entry into the U.S. (mm/dd/yyyy)
14. Current Immigration Status
15. Relationship to Principal (if applicable)
Part 2. Information About Principal Alien
1. Family Name
Given Name
Middle Name
State
2. Home Address - Street Number and Name
City
Zip Code
Apt. #
3. Date Tour of Duty Expected to End (mm/dd/yyyy)
4. Country of Citizenship
5. Marital Status
Married
Not Married
6. Job Title
7. I-94 # (Arrival-Departure Document)
8. DOS Personal Identification # (PID)
Part 3. Type of Request
(See instructions for complete information on the different types of requests. )
I am requesting employment authorization as (select one):
1.
a.
spouse.
son or daughter, age:
, who:
is a full-time, post-secondary student
is disabled
b.
c.
other dependent recognized by the DOS
2.
I am requesting change/adjustment of status (Select one)
a.
Change of nonimmigrant status to A, G, or NATO nonimmigrant - specifically to:
b.
Section 247(a), immigrant to A or G nonimmigrant.
c.
Change to other nonimmigrant status from A, G, or NATO - specifically to:
d.
Adjustment from A, G, or NATO nonimmigrant to immigrant.
A-1, A-2, G-1, or G-2, nonimmigrant applying under Section 13 of the Act of September 11, 1957.
e.
Part 4. Certification
(Submit two copies with original signatures - Page 2 must also be attached.)
I certify under penalty of perjury that the foregoing is true and correct. I understand false information is a basis for denial or termination of the
benefit requested and for other penalties provided by law and regulation. If I am requesting employment authorization, I further certify that I do not
have a criminal record. I have not violated United States immigration and/or visa laws, I have not worked illegally in the United States, and I have
paid Social Security and all applicable taxes on all employment in the United States.
Date (mm/dd/yyyy)
Signature of Applicant
Form I-566 (Rev. 01/18/11)Y
Copy 1:USCIS
Copy 2: DOS/NATO/HQ SACT/USUN/VISA OFFICE

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