OMB No. 1405-0126
Make sure the address is complete and correct. We will use this address for future mailings. EXPIRATION DATE: 02/28/2013
ESTIMATED BURDEN: 10 minutes*
Place Case Barcode Strip Here Before Mailing to the National Visa Center
U.S. Department of State
CHOICE OF ADDRESS AND AGENT
For Immigrant Visa Applicants
Print or Type your Full Name
(Last Name) (First Name) (MI.)
Check one box only to the left of the statement that is your choice.
I Appoint
Telephone Number
as my agent or attorney to receive mail about my application. Mail from the U.S. Department of
State concerning my immigrant visa application should be sent to:
Name of the person who will act as your agent or attorney for receipt of mail Telephone Number
Street Address (where my agent or attorney will receive mail about my application) *Email Address
City State/Province Postal Code Country
I do not appoint an agent or an attorney to receive mail about my application. Mail from the U.S.
Department of State concerning my immigrant visa application should be sent to me at:
Street Address (Include "in care of" if Needed) *Email Address
City State/Province Postal Code Country
I have already legally immigrated to the U.S. and do not need to apply for an immigrant visa. I
received my Green Card through the (City) USCIS office. My A# is
.
I no longer wish to apply for an immigrant visa.
As proof of your choice, sign and date this document:
Signature of Applicant Date of Signature (mm-dd-yyyy)
*The Department is currently testing an electronic application system for nonimmigrant visa application that will allow electronic submission and eliminate
paper forms. Once testing on this application system is completed the Department is examining whether or not the system can be used for the immigrant visa
system.
Paperwork Reduction Act Statement
*Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time required for searching existing data
sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to
supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.
Confidentiality Statement
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment,
administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a
court which certifies that the information contained in such records is needed in a case pending before the court.
American LegalNet, Inc.
DS-3032 www.FormsWorkFlow.com
06-2011