OMB No.

1405-0126
Make sure the address is complete and correct. We will use this address for future mailings. EXPIRATION DATE: 03-25-2027
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: PRA_BurdenComments@state.gov .

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.

DS-3032
03-2013
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Signature Signature
DHL Cargo Insurance –
Security all over the world*
The service DHL Cargo Insurance offers protection against the consequences of loss or
damage to your shipments.

DHL Paket GmbH, for the companies of Deutsche Post DHL that conclude contracts under these terms & conditions – ID no.: 156E – Mat.-No: 675-601-858 – Date: 01/2020 – 1 of 2
However much care we take of the goods entrusted to us, there is always the slight possibility that shipments may be
damaged – for example, in road traffic accidents. The actual damage caused to you may turn out to be greater than the liability or
insurance, which the product already includes.

If your goods are lost or damaged, DHL will refund the damage or loss caused in accordance with its General Terms & Conditions
(in the currently applicable version). Claims will be paid on the basis of the agreed liability. For shipments with the service cargo
insurance the claim will be paid according to insurance policy conditions.

Whenever the liability or the insurance already included in the product is insufficient, DHL recommends that you protect shipments
with valuable contents through an additional service cargo insurance. 1

The cargo insurance service provides coverage in case of loss of or damage to goods for parcels2 and express shipments, up to the
agreed amount.

TAKE ADVANTAGE OF THE BENEFITS OF DHL CARGO INSURANCE

Comprehensive protection
In general, insurance protection applies to the entire period of the transport (from the handover of the shipment to DHL until
its delivery).

Indemnification even without liability

You will receive compensation for damage of goods according to the agreed insurance conditions, even if the loss occurred
during transportation without DHL being responsible.

Avoid disputes
In case of loss or damage, the DHL Cargo Insurance can save you from disputes with suppliers or customers.

HOW THE COVERAGE COMES INTO EFFECT

Provided that you select the appropriate DHL cargo insurance and pay the additional charge, DHL will arrange comprehensive cargo
insurance protection. 3
Better safe than sorry: For all service specifications4 please talk to your DHL sales contact or to the customer service.

1
Please note: the relevant General Terms & Conditions place restrictions on sending certain particularly threatened goods (valuables). An infringement of this restriction will necessarily lead to
the exclusion of any liability and insurance coverage, i.e., in case of damage, no compensation will be paid for such shipments.
2
If the goods are sent by DHL Paket International or DHL Paket Connect, cargo insurance of up to EUR 500 is already included without additional charge.
3
DHL as the policy holder and entity responsible for paying the premiums will arrange in conjunction with its activity as carrier a cargo insurance, which covers your interest in the shipped goods
as coinsured through payment of the relevant additional charge.
4
Parcels and express shipments with the cargo insurance service may only be posted against confirmation of postage to Deutsche Post’s retail outlets und such parcels additionally in parcel shops
of DHL, but not to other posting facilities such as DHL Packstations or parcel boxes.

Cargo Insurance DHL Paket