Fillable Form I-539: Application to Extend/Change Nonimmigrant Status (American Immigration Lawyers Association)

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Form I-539: Application to Extend/Change Nonimmigrant Status (American Immigration Lawyers Association)

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Form I-539 Edition 10/15/19
Page 1 of 8
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 10/31/2021
Part 1. Information About You
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
U.S. Mailing Address
4.d. City or Town
4.a. In Care Of Name (if any)
4.e. State 4.f. ZIP Code
10. Date of Last Arrival Into the United States (mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)8.
►
U.S. Social Security Number (if any)9.
Street Number
and Name
4.b.
4.c. Ste. Flr.Apt.
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
Returned
Applicant interviewed on
Granted
Dates:
7. Country of Citizenship or Nationality
Country of Birth6.
Other Information About You
USCIS Online Account Number (if any)3.
►
►
A-
Alien Registration Number (A-Number) (if any)2.
Your Full Name
Apt.
Flr.Ste.5.b.
5.a. Street Number
and Name
ZIP Code5.e.State5.d.
City or Town5.c.
U.S. Physical Address
Form I-94 Arrival-Departure Record Number11.
►
Provide Information About Your Most Recent Entry Into the
United States
Select this box if
Form G-28 is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
To be completed by an
Attorney or Accredited
Representative (if any).
Passport Number12.
START HERE - Type or print in black ink.►
(USPS ZIP Code Lookup)
Form I-539 Edition 10/15/19
Page 2 of 8
Current Nonimmigrant Status (e.g. F-1 student, H-4
dependent, etc.)
15.a.
14.b.
Passport or Travel Document Expiration Date
(mm/dd/yyyy)
Expiration Date (mm/dd/yyyy) 15.b.
16. Select this box if you were granted Duration of Status
(D/S).
14.a. Country of Passport or Travel Document Issuance
Part 1. Information about You (continued)
1. Reinstatement to student status.
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 Form I-539A for each
co-applicant.)
2.
3.c.
A change of status.
The change of status I am requesting is:
I am applying for (select only one box):
Number of people included in this application (select only one
box):
Part 2. Application Type
5.b.
3.b.
3.a.
New status and effective date of change (mm/dd/yyyy)
►
If pending with USCIS, provide USCIS Receipt Number.3.b.
Date Filed (mm/dd/yyyy)5.
4. First and Last Name of Petitioner or Applicant
NoYes, filed with this Form I-539.
Yes, filed previously and pending with U.S.
Citizenship and Immigration Services (USCIS).
3.a. Is this application based on a separate petition or application
to provide your spouse, child, or parent an extension or
change of status?
If the petition or application is pending with USCIS, also
provide the following information:
Part 3. Processing Information
1. I/We request that my/our current or requested status be
extended until (mm/dd/yyyy):
2.a. Is this application based on an extension or change of
status already granted to your spouse, child, or parent?
NoYes
Provide Your Current Passport Information (if different from
Part 1.)
Part 4. Additional Information About the
Applicant
1.c. Passport Expiration Date (mm/dd/yyyy)
Country of Passport Issuance
Passport Number1.a.
1.b.
Physical Address Abroad
Street Number
and Name
2.a.
2.c. City or Town
2.d.
Province
2.e. Postal Code
2.f. Country
2.b. Ste. Flr.
Apt.
Answer the following questions. If you answer “Yes” to any of
the questions in Item Numbers 3. - 15., use the space provided
in Part 9. Additional Information to provide an explanation.
Travel Document Number13.
2.b. If you answered "Yes" to Item Number 2.a., provide
USCIS Receipt Number.
►
Form I-539 Edition 10/15/19
Page 3 of 8
3. Are you, or any other individual included on the
application, an applicant for an immigrant visa?
NoYes
5.
Have you, or any other individual 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 individual included in this application?
NoYes
Yes No
Has an immigrant petition EVER been filed for you or for
any other individual included in this application?
4.
Yes No
10. Have you, or any other individual 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
11. Have you, or any other individual included in this
application, EVER received any type of military,
paramilitary, or weapons training?
Yes No
12.
13. Are you, or any other individual included in this
application, now in removal proceedings?
Have you, or any other individual included in this
application, done anything that violated the terms of the
nonimmigrant status you now hold?
Yes No
Yes No
Part 4. Additional Information About the
Applicant (continued)
Have you, or any other individual 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 did not consent or was unable to consent,
or was being forced or threatened?
Intentionally and severely injuring any person?
Killing any person?
Acts involving torture or genocide?
NoYes
NoYes
NoYes
NoYes7.a.
7.b.
7.c.
7.d.
Limiting or denying any person's ability to exercise
religious beliefs?
7.e.
Yes No
Have you, or any other individual included on the application,
EVER:
Yes No
Have you, or any other individual included in this
application, EVER been a member of, assisted, 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?
9.
Served in, been a member of, assisted, or participated in any
military unit, paramilitary unit, police unit, self-defense unit,
vigilante unit, rebel group, guerrilla group, militia, insurgent
organization, or any other armed group?
Worked, volunteered, or otherwise served in any prison,
jail, prison camp, detention facility, labor camp, or any
other situation that involved detaining persons?
Yes No
8.a.
8.b.
NoYes
14.
NoYes
Have you, or any other individual included in this
application, been employed in the United States since last
admitted or granted an extension or change of status?
If you answered "Yes" to Item Number 13., provide the
following information concerning the removal proceedings in
the space provided in Part 9. Additional Information. Include
the name of the individual in removal proceedings and
information on jurisdiction, date proceedings began, and status
of proceedings.
If you answered "No" to Item Number 14., fully describe how
you are supporting yourself in Part 9. Additional Information.
Include documentary evidence of the source, amount, and basis
for any income.
If you answered "Yes" to Item Number 14., fully describe the
employment in Part 9. Additional Information. Include the
name of the individual employed, name and address of the
employer, weekly income, and whether the employment was
specifically authorized by USCIS.
If you answered "Yes" to Item Number 15., you must provide
the dates you maintained status as a J-1 exchange visitor or J-2
dependent in Part 9. Additional Information.
15. Are you, or any other individual 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
Form I-539 Edition 10/15/19
Page 4 of 8
Part 5. Public Benefits
1. Since obtaining the nonimmigrant status that you seek to
extend or from which you seek to change, have you
received, or are you currently certified to receive, any of
the following public benefits? (select all that apply)
Provide the requested information and submit documentation,
as outlined in the Instructions.
Yes, I have received or I am currently certified to
receive the following public benefits:
Supplemental Security Income (SSI)
General Assistance (GA)
Section 8 Housing Assistance under the Housing
Choice Voucher Program
Public Housing under the Housing Act of 1937,
42 U.S.C. 1437 et seq.
Federally-funded Medicaid
Section 8 Project-Based Rental Assistance
(including Moderate Rehabilitation)
Supplemental Nutrition Assistance Program
(SNAP, formerly called “Food Stamps”)
Temporary Assistance for Needy Families
(TANF)
Any Federal, State, local or tribal cash assistance
for income maintenance
No, I am not certified to receive any of the above
listed public benefits.
No, I have not received any of the above listed public
benefits.
2. If you have received or are currently certified to receive
any of the above public benefits provide information
about the public benefits below. If you need extra space
to complete this section, use the space provided in Part 9.
Additional Information. Submit documentation as
outlined in the Instructions.
A. Type of Benefit
Agency That Granted The Benefit
Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts
(mm/dd/yyyy)
B. Type of Benefit
Agency That Granted The Benefit
Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
C. Type of Benefit
Agency That Granted The Benefit
Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
D. Type of Benefit
Agency That Granted The Benefit
Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
3. If you answered “Yes” to Item Number 1., do any of the
following apply to you? (select the applicable box).
Provide the evidence listed in the Instructions if any of the
following apply to you.
I am enlisted in the Armed Forces, or am serving in
active duty or in the Ready Reserve Component of
the U.S. Armed Forces.
I am the spouse or the child of an individual who is
enlisted in the Armed Forces, or who is serving in
active duty or in the Ready Reserve Component of
the U.S. Armed Forces.
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
Form I-539 Edition 10/15/19
Page 5 of 8
Part 5. Public Benefits (continued)
At the time I received the public benefits, I was
present in the United States in a status exempt from
the public charge ground of inadmissibility.
I am a child currently residing abroad who entered
the United States with a nonimmigrant visa to attend
an N-600K, Application for Citizenship and Issuance
of Certificate Under INA Section 322 interview.
At the time I received the public benefits, I was
present in the United States after being granted a
waiver off the public charge ground of
inadmissibility.
None of the above statements apply to me.
At the time I received the public benefits, I (or my
spouse or parent) was enlisted in the Armed Forces,
or was serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.
Have you received, applied for, or have been certified to
receive federally-funded Medicaid in connection with any
of the following (select all that apply) (Submit evidence
as outlined in the Instructions):
4.a.
For a service under the Individuals with Disabilities
Education Act (IDEA).
While you were under the of age 21.
Other school-based benefits or services available up
to the oldest age eligible for secondary education
under state law.
None of the above statements apply to me.
An emergency medical condition.
While you were pregnant or during the 60-day period
following the last day of pregnancy.
Provide the applicable dates:4.b.
From (mm/dd/yyyy)
To (mm/dd/yyyy)
5. Applicant's Email Address (if any)
3.
Applicant's Mobile Telephone Number (if any)4.
Applicant's Daytime Telephone Number
Applicant's Contact Information
,
2.
At my request, the preparer named in Part 8.
prepared this application for me based only upon
information I provided or authorized.
Part 6. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.b.
The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in
a language in which I am fluent, and I understood
everything.
,
Applicant's 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
application, 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)
All of this information was complete, true, and correct
at the time of filing.
2)
I reviewed and understood all of the information
contained in, and submitted with, my application; and
I certify, under penalty of perjury, that all of the information in
my application 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
application and that all of this information is complete, true, and
correct.
Form I-539 Edition 10/15/19
Page 6 of 8
Part 6. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
Federal Agency Disclosure and Authorizations
I authorize, as applicable, the Social Security Administration
(SSA) to verify my Social Security number (to match my name,
Social Security number, and date of birth with information in
SSA records and provide the results of the match) to USCIS. I
authorize SSA to provide explanatory information to USCIS as
necessary.
I understand that the information released by records custodians
and sources of information is for official use by the Federal
Government, that the U.S. Government will use it only to
review if I have received public benefits in regards to my
eligibility for immigration benefits and to enforce immigration
laws, and that the U.S. Government may disclose the
information only as authorized by law.
I authorize, as applicable, custodians of records and other
sources of information pertaining to my request for or receipt of
public benefits to release information regarding my request for
and/or receipt of public benefits, upon the request of the
investigator, special agent, or other duly accredited
representative of any Federal agency authorized above,
regardless of any previous agreement to the contrary.
I authorize, as applicable, the SSA, U.S. Department of
Agriculture (USDA), U.S. Department of Health and Human
Services (HHS), U.S. Department of Housing and Urban
Development (HUD), and any other U.S. Government agency
that has received and/or adjudicated a request for a public
benefit, as defined in 8 CFR 212.21(b), submitted by me or on
my behalf, and/or granted one or more public benefits to me, to
disclose to USCIS that I have applied for, received, or have
been certified to receive, a public benefit from such agency,
including the type and amount of benefits, dates of receipt, and
any other relevant information provided to the agency for the
purpose of obtaining such public benefit, to the extent permitted
by law. I also authorize SSA, USDA, HHS, HUD, and any
other U.S. Government agency to provide any additional data
and information to USCIS, to the extent permitted by law.
Date of Signature (mm/dd/yyyy) 6.b.
Applicant's Signature6.a.
Applicant's Signature
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Part 7. Interpreter's Contact Information,
Statement, Certification, and Signature
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Provide the following information about the interpreter.
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)
Interpreter's Business or Organization Name (if any)2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
which is the same language specified in Part 6., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Form I-539 Edition 10/15/19
Page 7 of 8
Part 7. Interpreter's Contact Information,
Statement, Certification, and Signature
(continued)
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Interpreter's Signature
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Business or Organization Name2.
Provide the following information about the preparer.
3.h.
3.g. Postal Code
Country
3.f. Province
Preparer's Mailing Address
3.c.
City or Town
3.d.
State
3.e.
ZIP Code
Street Number
and Name
3.a.
3.b. Ste. Flr.Apt.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
7.b.
preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends does not extend beyond the
NOTE: If you are an attorney or accredited representative, you
may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this
application.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
7.a.
Preparer's Statement
Form I-539 Edition 10/15/19
Page 8 of 8
Part 9. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.
A-Number (if any)
►
A-
3.a.
2.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
Page Number Part Number Item Number
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
4.c.4.b.
4.d.
4.a.
Page Number Part Number Item Number5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
Part NumberPage Number Item Number
6.d.
6.c.6.b.6.a.
7.c.7.b.7.a.
7.d.
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Form I-539: Application to ExtendChange Nonimmigrant Status (American Immigration Lawyers Association)

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Completed 29 July 2020

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