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
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
If you selected “Change of Nonimmigrant Status” TO or
FROM “A, G, or NATO,” provide the specific category
NOTE: Form I-566 is not required if you have changed from
A, G, or NATO nonimmigrant status to asylum (protected)
Part 3. Type of Request (continued)
Part 4. Requestor's Statement, Contact
Information, Declaration, Certification, and
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
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.
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
a language in which I am fluent, and I understood
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)
Requestor's Daytime Telephone Number3.
Requestor's Mobile Telephone Number (if any)
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
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.
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.