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 USCIS office. My A# is
Make sure the address is complete and correct. We will use this address for future mailings.
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
Check one box only to the left of the statement that is your choice.
OMB No. 1405-0126
EXPIRATION DATE: 12/31/2006
ESTIMATED BURDEN: 10 minutes*
Print or Type your Full Name
Signature of Applicant
Date of Signature (mm-dd-yyyy)
I no longer wish to apply for an immigrant visa.
As proof of your choice, sign and date this document:
Street Address (Include "in care of" if Needed)
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:
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:
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.
PAPERWORK REDUCTION ACT
Name of the person who will act as your agent or attorney for receipt of mail
Street Address (where my agent or attorney will receive mail about my application)
*The Department is currently testing an electronic application system for nonimmigrant visa application that