Fillable Form G-28 is: Interagency Record of Request - (Visa Pro)

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Form G-28 is: Interagency Record of Request - (Visa Pro)

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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. Gender Male
Female
7. Country of Citizenship or Nationality
Marital 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)
Other
Marriage AnnulledLegally Separated
MarriedSingle Divorced
Widowed
Other Information
5. 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 Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Street Number
and Name
2.b.
2.d. City or Town
2.e. State 2.f. ZIP Code
2.c.
Ste.
Flr.Apt.
In Care Of Name (if any)2.a.
U.S. Mailing Address
NOTE: 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 Address
Street Number
and Name
4.a.
4.c. City or Town
4.d. State 4.e. ZIP Code
4.b.
Ste. Flr.
Apt.
To be completed by an
attorney or accredited
representative (if any).
USCIS
Form I-566
OMB No. 1615-0027
Expires 04/30/2021
START HERE - Type or print in black ink.►
A-Number:
(USPS ZIP Code Lookup)
FOR USCIS OFFICE ONLY
Remarks:
NOTE: If you answered “No” to Item Number 3., provide
your physical address in Item Numbers 4.a. - 4.e.
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 Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Principal Alien's U.S. Physical Address
Street Number
and Name
2.a.
2.c. City or Town
2.d. State 2.e. ZIP Code
2.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 States
9.a. Form I-94 Arrival-Departure Record Number (if any)
►
Passport or Travel Document Number9.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 Authorization
I am a/an (select only one box):2.a.
Spouse
Son or Daughter
Other Dependent Recognized by DOS
If you selected “Son or Daughter,” 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 “Other Dependent Recognized by DOS,”
provide your category below.
If you selected a status in Item Number 2.b., provide
your age.
2.c.
Marital Status
6.
Other
Marriage AnnulledLegally Separated
MarriedSingle Divorced
Widowed
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 “Change of Nonimmigrant Status” TO or
FROM “A, G, or NATO,” 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. Requestor's Statement, Contact
Information, Declaration, Certification, and
Signature
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.
Requestor's Statement
NOTE: 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 in
1.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 Information
Requestor'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 Certification
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 Signature6.a.
6.b. Date of Signature (mm/dd/yyyy)
Requestor's Signature
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.
Form I-566 04/09/19
Page 4 of 8
Interpreter's Certification
I 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 Signature
Interpreter's Signature7.a.
7.b. Date of Signature (mm/dd/yyyy)
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)
Preparer's Given Name (First Name)1.b.
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.c. City or Town
Street Number
and Name
3.a.
3.b.
Ste. Flr.Apt.
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)
Interpreter's Business or Organization Name (if any)2.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Ste. Flr.
Apt.
3.h.
3.f. Province
Country
3.g. Postal Code
Interpreter's Daytime Telephone Number
6.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Mobile Telephone Number (if any) 5.
3.d. State 3.e. ZIP Code
3.h.
3.f. Province
Country
3.g. Postal Code
Form I-566 04/09/19
Page 5 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
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Mobile Telephone Number (if any)5.
Preparer's Statement
I am an attorney or accredited representative and my
representation of the requestor in this case
preparation of this request.
I am not an attorney or accredited representative but
have prepared this request on behalf of the requestor
and with the requestor's consent.
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.
7.a.
7.b.
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
Preparer's Signature 8.a.
8.b. Date of Signature (mm/dd/yyyy)
extends does not extend beyond the
Form I-566 04/09/19
Page 6 of 8
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.
A-Number (if any) ►
A-
3.a.
2.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
Page Number
Part Number Item Number
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
4.c.4.b.
4.d.
4.a.
Page Number Part Number Item Number5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
Part NumberPage Number Item Number
6.d.
6.c.6.b.6.a.
7.c.7.b.7.a.
7.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 04/09/19
Page 7 of 8
Part 8. Certification by Diplomatic Mission,
International Organization, NATO/HQ SACT,
or NATO Member State
FOR OFFICIAL USE ONLY
NOTE: Certifying officer or official must have this
information and page to complete process.
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.
1.
I further certify that the principal alien is being
offered the following position:
3.a.
I further certify that the requestor's eligibility for
employment authorization was verified under the
provisions of a (select only one box):
2.a.
Bilateral De facto Arrangement
Bilateral Agreement
2.b.
Name of the Country With Which the Agreement or
Arrangement was Made
Select all applicable boxes.2.c.
Without a Numerical Limit
With a Numerical Limit and This Requestor is
Within the Limit
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
Certifying Official's Signature
Certifying Official's Signature8.a.
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
9.d. City or Town
9.e. State 9.f. ZIP Code
9.g.
Postal Code9.h.
Province
9.i. Country
Street Number
and Name
9.b.
9.c.
Ste. Flr.Apt.
Official Seal
For Change/Adjustment of Status
G-4 Regulations
Additional Information About Agreement or Arrangement
Certifying Official's Title5.
Certifying Official's Daytime Telephone Number6.
7. Certifying Official's Email Address (if any)
Form I-566 04/09/19
Page 8 of 8
Part 9. DOS, NATO/HQ SACT, and/or DOS
USUN Information
FOR OFFICIAL USE ONLY
Recommendation from DOS, NATO/HQ SACT, and/or
DOS USUN
1.a.
Deny Request
Grant Request
1.b.
If you selected “Deny Request,” provide the reasons for
the recommendation.
2. Date of Recommendation (mm/dd/yyyy)
Office Providing Recommendation3.
DOS ProtocolDOS OFM DOS Visa
DOS USUN Host Country
Signature and Contact Information for
Recommending Official
4.a.
Recommending Official's Daytime Telephone Number4.b.
Recommending Official's Signature
Part 10. USCIS Information
3. Office Telephone Number (including area code)
USCIS Office2.
FOR OFFICIAL USE ONLY
Information About USCIS Immigration Services
Officer (ISO)
ISO's Identification Number1.
Information About USCIS Action Taken on This
Request
Where was USCIS decision sent?4.
DOS OFM DOS Protocol
DOS Visa
NATO/HQ SACT DOS USUN Host Country
NOTE: If the requestor filed under 8 U.S.C. 1255b
(“Section 13”), advise USCIS of findings.
For Change/Adjustment of Status only:
Decision for Employment Authorization Request6.a.
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)
Decision for Change/Adjustment of Status5.a.
Granted
Denied
5.b. Date of Decision (mm/dd/yyyy)
5.c. If you selected “Granted,” provide the new status below.
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Form G-28 is: Interagency Record of Request - (Visa Pro)

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Completed 29 July 2020

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