Form I-539A 02/04/19
Page 2 of 4
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)
4.
Applicant's Contact Information
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
I furthermore authorize release of information contained in this
form, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my form; and
2) All of this information was complete, true, and correct
at the time of filing.
I certify, under penalty of perjury, that all of the information in
my form and any document submitted with it were provided or
authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my form and that
all of this information is complete, true, and correct.
Date of Signature (mm/dd/yyyy) 6.b.
Applicant's Signature6.a.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this form or fail to submit required documents listed in the
Instructions, USCIS may deny the Form I-539 filed on your
behalf.
Applicant's Signature
Part 4. Interpreter's Contact Information,
Statement, Certification, and Signature
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Provide the following information about the interpreter you
used to complete Form I-539A if he or she is different from the
interpreter used to complete the Form I-539 filed on your
behalf.
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.g. Postal Code
Street Number
and Name
3.a.
Country
3.b.
Ste. Flr.Apt.
3.f. Province
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)
6.
5. Interpreter's Mobile Telephone Number (if any)
which is the same language specified in Part 3., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this form and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
form, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
(USPS ZIP Code Lookup)
