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Make sure the address is complete and correct. We will use this address for future mailings.

OMB No. 1405-0126 EXPIRATION DATE: 12/31/2006 ESTIMATED BURDEN: 10 minutes*

Place Case Barcode Strip Here Before Mailing to the National Visa Center

CHOICE OF ADDRESS AND AGENT
For Immigrant Visa Applicants
Print or Type your Full Name

U.S. Department of State

Check one box only to the left of the statement that is your choice. I Appoint
Telephone Number

(Last Name)

(First Name)

(MI.)

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 (City) USCIS office. My A# is received my Green Card through the
.

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)

PAPERWORK REDUCTION ACT
Public reporting burden for this collection of information is estimated to average 10 minutes per response. Persons are not required to provide this information in the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520-1849. *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. DS-3032 10-2006