Form I-539 04/06/15 N
Application to Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-539
OMB No. 1615-0003
Expires 04/30/2018
Part 1. Information About You
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
Middle Name
Mailing Address
4.d.
Ste. Flr.
Apt.5.b.
5.a. Street Number
and Name
ZIP Code5.e.State5.d.
City or Town5.c.
City or Town
4.a. In Care Of Name
4.e. State 4.f. ZIP Code
10. Date of Last Arrival Into the United States
(mm/dd/yyyy)
(mm/dd/yyyy)Date of Birth 8.
U.S. Social Security Number (if any)9.
Street Number
and Name
4.b.
I-94 Arrival-Departure Record Number11.a.
4.c. Apt.
Flr.Ste.
Current Nonimmigrant Status12.a.
Remarks:
New Class
Denied
Still within period of stay
S/D to:
Place under docket control
From / / /
To / / /
For USCIS Use Only
Action Block
Sent
Received
Relocated
Fee Stamp
Resubmitted
To Be Completed by an Attorney
or Accredited Representative, if any.
Select this box if G-28 is attached to represent the applicant.
Attorney State License Number:
Returned
Applicant interviewed on
Granted
Dates:
Physical Address
Passport Number11.b.
Travel Document Number11.c.
11.d. Country of Issuance for Passport or Travel Document
11.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
7. Country of Citizenship or Nationality
(mm/dd/yyyy)Expiration Date 12.b.
12.c. Check this box if you were granted Duration of Status
(D/S).
Country of Birth6.
USCIS ELIS Account Number (if any)2.
A-
Alien Registration Number (A-Number)1.
Other Information
Provide information about your most recent Form I-94
Page 1 of 9
Norwalk Comm Coll-Internation Svcs
188 Richards Ave
Norwalk
06854
CT
Form I-539 04/06/15 N
1. An extension of stay in my current status.
4. I am the only applicant.
5.a.
Members of my family are filing this application with
me.
The total number of people (including me) in the
application is: (Complete the supplement for each
co-applicant.)
2.a.
2.b.
A change of status. The new status and effective date
The change of status I am requesting is:
3.
Reinstatement to student status.
I am applying for: (Select one)
Number of people included in this application: (Select one)
Part 2. Application Type (See instructions for fee)
5.b.
2.b. If "Yes," provide USCIS Receipt Number.
Part 3. Processing Information
1.a.
1.b.
I/We request that my/our current or requested status be
2.a. Is this application based on an extension or change of
status already granted to your spouse, child, or parent?
(mm/dd/yyyy)
NoYes
If pending with USCIS, provide USCIS Receipt Number
Office where petition or application filed:
3.b.
(mm/dd/yyyy)Date Filed3.f.
3.c. First and last name of petitioner or applicant
3.d. City or Town
3.e.
State
If you are the Principal Applicant, provide your current Passport
information:
Part 4. Additional Information
1.b. Expiration Date for Passport
(mm/dd/yyyy)
Country of Issuance for Passport1.a.
Foreign Home Address
Street Number
and Name
2.a.
2.c. City or Town
2.d.
Province
2.e. Postal Code
2.f. Country
NoYes, filed with this I-539.
Yes, filed previously and pending with USCIS.
3.a. Is this application based on a separate petition or application
to give your spouse, child, or parent an extension or change
of status?
If the petition or application is pending with USCIS, also give
the following data:
2.b. Apt. Flr.Ste.
3.
5.
Have you, or any other person included in this application,
EVER been arrested or convicted of any criminal offense
since last entering the United States?
6.
Has Form I-485, Application to Register Permanent
Residence or Adjust Status, EVER been filed by you or
by any other person included in this application?
NoYes
Has an immigrant petition EVER been filed for you or for
any other person included in this application?
4.
Answer the following questions. If you answer "Yes" to any
question, describe the circumstances in detail and explain on a
separate sheet of paper.
Are you, or any other person included on the application,
an applicant for an immigrant visa?
NoYes
Have you, or any other person included on the application,
EVER ordered, incited, called for, committed, assisted, helped
with, or otherwise participated in any of the following:
Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Intentionally and severely injuring any person?
Killing any person?
Acts involving torture or genocide?
NoYes
NoYes
NoYes
NoYes7.
8.
9.
10.
Yes No
Yes No
extended until
(mm/dd/yyyy)of change.
Check this box if you were granted, or are seeking,
Duration of Status (D/S).
Limiting or denying any person's ability to exercise
religious beliefs?
11.
Yes No
Page 2 of 9
Form I-539 04/06/15 N
Yes
15.
16.
17.
18.
19.
NoYes
No
Have you, or any other person included in this application,
EVER been a member of, assisted in, or participated in
any group, unit, or organization of any kind in which you
or other persons used any type of weapon against any
person or threatened to do so?
14.
Have you, or any other person included on the application,
EVER served in, been a member of, assisted in, or
participated in any military unit, paramilitary unit, police
unit, self-defense unit, vigilante unit, rebel group, guerrilla
group, militia, or insurgent organization?
Have you, or any other person included in this application,
EVER served in any prison, jail, prison camp, detention
facility, labor camp, or any other situation that involved
detaining persons?
Have you, or any other person included in this
application, been employed in the United States since last
admitted or granted an extension or change of status?
Are you, or any other person included in this application,
now in removal proceedings?
If "Yes," provide the following information concerning the
removal proceedings in Part 4. Additional Information for
Answers to Item Numbers 18., 19., and 20. Include the name
of the person in removal proceedings and information on
jurisdiction, date proceedings began, and status of proceedings.
Have you, or any other person included in this
application, done anything that violated the terms of the
nonimmigrant status you now hold?
Have you, or any other person included in this application,
EVER received any type of military, paramilitary, or
weapons training?
Have you, or any other person included in this application,
EVER assisted or participated in selling, providing, or
transporting weapons to any person who to your
knowledge, used them against another person?
Yes No
12.
13.
Part 4. Additional Information (continued)
If "Yes," you must provide the dates you maintained status as a
J-1 exchange visitor or J-2 dependent in Part 4. Additional
Information for Answers to Item Numbers 18., 19. and 20.
NoYes
Yes No
Yes No
Yes No
Yes No
Part 5. Applicant's Statement, Contact
Information, Certification and Signature
If "No," fully describe how you are supporting yourself in
Part 4. Additional Information for Answers to Item
Numbers 18., 19., and 20. Include documentary evidence of
the source, amount, and basis for any income.
If "Yes," fully describe the employment in Part 4. Additional
Information for Answers to Item Numbers 18., 19., and 20.
Include the name of the person employed, name and address of
the employer, weekly income, and whether the employment was
specifically authorized by USCIS.
Applicant's Certification
I certify, under penalty of perjury, that the information in my
form and any document submitted with my form is true and
correct. 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 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 laws.
(mm/dd/yyyy)Date of Signature3.b.
Applicant's Signature3.a.
I can read and understand English, and have read and
understand each and every question and instruction
on this form, as well as my answer to every question.
1.b.
The interpreter named in Part 6. has also read to me
every question and instruction on this form, as well
as my answer to every question, in
1.a.
a language in which I am fluent. I understand every
question and instruction on this form as translated to
me by my interpreter, and have provided true and
correct responses in the language indicated above.
,
,
2. I have requested the services of and consented to
who is
representative, preparing this form for me.
is not an attorney or accredited
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
20. Are you, or any other person included in this application,
currently or have you ever been a J-1 exchange visitor or
a J-2 dependent of a J-1 exchange visitor?
Yes No
Page 3 of 9
Form I-539 04/06/15 N
Part 5. Applicant's Statement, Contact Information,
Certification and Signature (continued)
Applicant's Daytime Telephone Number4.
Applicant's E-mail Address6.
Applicant's Mobile Telephone Number
5.
Part 6. Contact Information, Statement,
Certification, and Signature of the Interpreter
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 concerning the interpreter:
Applicant's Contact Information
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. Apt.
Flr.Ste.
3.f. Province
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's E-mail Address5.
Interpreter Certification
I certify that:
is the same language provided in Part 5., Item Number 1.b.;
I am fluent in English and , which
(mm/dd/yyyy)Date of Signature6.b.
Interpreter's Signature6.a.
I have read to this applicant every question and instruction on
this form, as well as the answer every question, in the language
provided in Part 5., Item Number 1.b.; and
The applicant has informed me that he or she understands every
instruction and question on the form, as well as the answer to every
question, and the applicant verified the accuracy of every answer..
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 7. Contact Information, Certification, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
Preparer's Business or Organization Name2.
Preparer's Mailing Address
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.g. Postal Code
Country
3.f. Province
Page 4 of 9
Form I-539 04/06/15 N
Part 7. Contact Information, Certification, and
Signature of the Person Preparing this
Application, If Other than the Applicant
(continued)
I am not an attorney or accredited representative but
have prepared this form on behalf of the applicant
and with the applicant's consent.
7.a.
7.b.
beyond the preparation of this form.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's E-mail Address
5. Preparer's Fax Number
I am an attorney or accredited representative and my
representation of the applicant in this case
(choose one) extends does not extend
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, swear or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the applicant. I completed this
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with every
answer on the form. If the applicant supplied additional
information concerning a question on the form, I recorded it on
the form.
Page 5 of 9
Form I-539 04/06/15 N
Part 4. (continued) Additional Information for
Answers to Item Numbers 18., 19., and 20.
If you answered "Yes" to Item Number 19. in Part 4. of this
form, fully describe the employment. Include the name of the
person employed, name and address of the employer, weekly
income, and whether the employment was specifically
authorized by USCIS.
If you answered "No" to Item Number 19. in Part 4. of this
form, fully describe how you are supporting yourself. Include
the source, amount, and basis for any income.
If you answered "Yes" to Item Number 18. in Part 4. of this
form, give the following information concerning the removal
proceedings. Include the name of the person in removal
proceedings and information on jurisdiction, date proceedings
began, and status of proceedings.
1.
3.
2.
If you answered "Yes" to Item Number 20. in Part 4. of this
form, list the name and dates of the person or persons who
maintained status as a J-1 exchange visitor or J-2 dependent.
4.
Page 6 of 9
Form I-539 04/06/15 N
Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.)
1.a.
2.p. Expiration Date (mm/dd/yyyy)
2.o. Current Nonimmigrant Status
2.h. Alien Registration Number (A-Number)
A-
I-94 Arrival/Departure Record Number2.j.
2.g. U.S. Social Security Number (if any)
2.d.
Date of Arrival2.i.
Date of Birth (mm/dd/yyyy)
(mm/dd/yyyy)
Country of Citizenship or Nationality2.f.
2.e. Country of Birth
Middle Name
2.c.
Given Name
(First Name)
2.b.
Family Name
(Last Name)
2.a.
Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Country of Birth1.e.
1.f. Country of Citizenship or Nationality
(mm/dd/yyyy)
(mm/dd/yyyy)Date of Birth
1.i. Date of Arrival
1.d.
U.S. Social Security Number (if any)1.g.
1.j. I-94 Arrival/Departure Record Number
A-
Alien Registration Number (A-Number)1.h.
Current Nonimmigrant Status1.o.
(mm/dd/yyyy)Expiration Date1.p.
Person One
Person Two
Passport Number
(mm/dd/yyyy)
Expiration Date for Passport or Travel Document2.n.
Country of Issuance for Passport or Travel Document2.m.
2.l. Travel Document Number
2.k. Passport Number
1.k.
Travel Document Number1.l.
1.m.
Country of Issuance for Passport or Travel Document
1.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Page 7 of 9
Form I-539 04/06/15 N
Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.) (continued)
Person Three
Person Four
3.a.
4.p. Expiration Date (mm/dd/yyyy)
4.o. Current Nonimmigrant Status
4.h. Alien Registration Number (A-Number)
A-
I-94 Arrival/Departure Record Number4.j.
4.g. U.S. Social Security Number (if any)
4.d.
Date of Arrival4.i.
Date of Birth (mm/dd/yyyy)
(mm/dd/yyyy)
Country of Citizenship or Nationality4.f.
4.e. Country of Birth
Middle Name
4.c.
Given Name
(First Name)
4.b.
Family Name
(Last Name)
4.a.
Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
Middle Name
Country of Birth3.e.
3.f. Country of Citizenship or Nationality
(mm/dd/yyyy)
(mm/dd/yyyy)Date of Birth
3.i. Date of Arrival
3.d.
U.S. Social Security Number (if any)3.g.
3.j. I-94 Arrival/Departure Record Number
A-
Alien Registration Number (A-Number)3.h.
Current Nonimmigrant Status3.o.
(mm/dd/yyyy)Expiration Date3.p.
Passport Number
(mm/dd/yyyy)
Expiration Date for Passport or Travel Document4.n.
Country of Issuance for Passport or Travel Document4.m.
4.l.
Travel Document Number
4.k. Passport Number
3.k.
Travel Document Number3.l.
3.m.
Country of Issuance for Passport or Travel Document
3.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Page 8 of 9
Form I-539 04/06/15 N
Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.) (continued)
Person Six
Person Five
5.a.
6.p. Expiration Date (mm/dd/yyyy)
6.o. Current Nonimmigrant Status
6.h. Alien Registration Number (A-Number)
A-
I-94 Arrival/Departure Record Number6.j.
6.g. U.S. Social Security Number (if any)
6.d.
Date of Arrival6.i.
Date of Birth (mm/dd/yyyy)
(mm/dd/yyyy)
Country of Citizenship or Nationality6.f.
6.e. Country of Birth
Middle Name
6.c.
Given Name
(First Name)
6.b.
Family Name
(Last Name)
6.a.
Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c.
Middle Name
Country of Birth5.e.
5.f. Country of Citizenship or Nationality
(mm/dd/yyyy)
(mm/dd/yyyy)Date of Birth
5.i. Date of Arrival
5.d.
U.S. Social Security Number (if any)5.g.
5.j. I-94 Arrival/Departure Record Number
A-
Alien Registration Number (A-Number)5.h.
Current Nonimmigrant Status5.o.
(mm/dd/yyyy)Expiration Date5.p.
Passport Number
(mm/dd/yyyy)
Expiration Date for Passport or Travel Document6.n.
Country of Issuance for Passport or Travel Document6.m.
6.l. Travel Document Number
6.k. Passport Number
5.k.
Travel Document Number5.l.
5.m.
Country of Issuance for Passport or Travel Document
5.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Page 9 of 9
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