Form I-566 - Interagency Record Of Request - A, G Or Nato Dependent Employment Authorization Or Change/adjustment To/from A, G Or Nato Status Page 3

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Part 5. Interpreter's Contact Information,
Part 4. Requestor's Statement, Contact
Certification, and Signature
Information, Certification, and Signature
(continued)
Provide the following information about the interpreter.
2.
At my request, the preparer named in Part 6.,
Interpreter's Full Name
,
1.a.
Interpreter's Family Name (Last Name)
prepared this request for me based only upon
information I provided or authorized.
1.b.
Interpreter's Given Name (First Name)
Requestor's Contact Information
3.
Requestor's Daytime Telephone Number
2.
Interpreter's Business or Organization Name (if any)
4.
Requestor's Mobile Telephone Number (if any)
Interpreter's Mailing Address
5.
Requestor's Email Address (if any)
3.a.
Street Number
and Name
3.b.
Apt.
Ste.
Flr.
Requestor's Certification
3.c. City or Town
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
3.d. State
3.e. ZIP Code
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
3.f.
Province
from any of my records that USCIS may need to determine my
eligibility for the immigration benefit I seek.
3.g. Postal Code
I further authorize release of information contained in this
3.h.
Country
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 laws.
Interpreter's Contact Information
I certify, under penalty of perjury, that I provided or authorized
all of the information in my request, I understand all of the
4.
Interpreter's Daytime Telephone Number
information contained in, and submitted with my request, and
that all of this information is complete, true, and correct.
5.
Interpreter's Email Address (if any)
Requestor's Signature
6.a. Requestor's Signature
Interpreter's Certification
I certify, under penalty or perjury, that:
6.b. Date of Signature (mm/dd/yyyy)
I am fluent in English and
, which
NOTE TO ALL REQUESTORS: If you do not completely
is the same language specified in Part 4., Item Number 1.b.,
fill out this request or fail to submit required documents listed
and I have read to this requestor in the identified language every
in the Instructions, USCIS may deny your request.
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 Certification, and has
verified the accuracy of every answer.
Form I-566 12/07/16 N
Page 3 of 7

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