Fillable Form I-539a Supplemental Information for Application to Extend/Change Nonimmigrant Status (USCIS)

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Form I-539a Supplemental Information for Application to Extend/Change Nonimmigrant Status (USCIS)

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The Form I-539a Supplemental Information for Application to Extend/Change Nonimmigrant Status (USCIS) form is 6 pages long and contains:

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-539A Edition 10/15/19 Page 1 of 6
Supplemental Information for Application to
Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-539A
OMB No. 1615-0003
Expires 10/31/2021
Part 2. Information About You
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
7. Date of Arrival (mm/dd/yyyy)
►
A-
Alien Registration Number (A-Number) (if any)6.
Form I-94 Arrival-Departure Record Number8.
►
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 BIA-
accredited
representative (if any).
Passport Number9.
Travel Document Number10.
START HERE - Type or print in black ink.►
Attach to Form I-539 when more than one person is included in
the Form I-539 application. List each person on a separate
Form I-539A. Do not include the person named in Form I-539.
Date of Birth (mm/dd/yyyy)2.
Country of Birth3.
4. Country of Citizenship or Nationality
►
U.S. Social Security Number (if any)
5.
Provide Information About Your Most Recent Entry Into the
United States
Provide Your Current Passport Information (if different from
Item Number 9.)
Passport Number13.a.
USCIS Online Account Number (if any)14.
►
13.b. Country of Passport Issuance
13.c.
Passport Expiration Date
(mm/dd/yyyy)
11.b. Passport or Travel Document Expiration Date
Current Nonimmigrant Status12.a.
Expiration Date (mm/dd/yyyy) 12.b.
Part 1. Information About the Person Filing
Form I-539
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Part 3. 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 certified to receive the
following public benefits
(select all that apply):
Supplemental Security Income (SSI)
General Assistance (GA)
Temporary Assistance for Needy Families
(TANF)
Any Federal, State, local or tribal cash assistance
for income maintenance
Supplemental Nutrition Assistance Program
(SNAP, formerly called “Food Stamps”)
11.a. Country of Passport or Travel Document Issuance
(mm/dd/yyyy)
Form I-539A Edition 10/15/19 Page 2 of 6
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)
No, I am not certified to receive any of the above
listed public benefits.
No, I have not received any of the above public
benefits.
2. If you 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 7.
Additional Information. Submit evidence 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)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
Part 3. Public Benefits (continued)
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)
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 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.
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.
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.
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 and I
received the public benefits during that time.
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 of the public charge ground of inadmissibility.
None of the above statements apply to me.
Section 8 Housing Assistance under the Housing
Choice Voucher Program
C. Type of Benefit
Agency That Granted The Benefit
Form I-539A Edition 10/15/19 Page 3 of 6
Part 3. Public Benefits (continued)
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)
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature
NOTE: Read the Penalties section of the Form I-539 and
Form I-539A Instructions before completing this section.
I can read and understand English, and I have read
and understand every question and instruction on this
form and my answer to every question.
1.a.
Applicant's Statement
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 5. read to me every
question and instruction on this form and my answer
to every question in
a language in which I am fluent, and I understood
everything.
,
At my request, the preparer named in Part 6.,
,
2.
prepared this form for me based only upon
information I provided or authorized.
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 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.
Federal Agency Disclosure and Authorizations
I authorize 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 authorize the SSA, U.S. Department of Agriculture (USDA),
U.S. Department of Health and Human Services (HHS), the
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
Form I-539A Edition 10/15/19 Page 4 of 6
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
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.
I authorize 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 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.
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
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
(USPS ZIP Code Lookup)
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)
Part 5. 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.
which is the same language specified in Part 4., 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 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 ,
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Interpreter's Signature
Form I-539A Edition 10/15/19 Page 5 of 6
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Part 6. 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 you used
to complete Form I-539A if he or she is different from the
preparer used to complete the Form I-539 filed on your behalf.
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.
preparation of this form.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends does not extend beyond the
Preparer's Statement
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 form.
By my signature, I certify, under penalty of perjury, that I
prepared this form at the request of the applicant. The applicant
then reviewed this completed form and informed me that he or
she understands all of the information contained in, and
submitted with, his or her form, including the Applicant's
Declaration and Certification, and that all of this information
is complete, true, and correct. I completed this form based only
on information that the applicant provided to me or authorized
me to obtain or use.
Preparer's Certification
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)
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Form I-539A Edition 10/15/19 Page 6 of 6
Part 7. Additional Information
If you need extra space to provide any additional information
within this form, 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-539a Supplemental Information for Application to ExtendChange Nonimmigrant Status (USCIS)

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Completed 11 August 2020

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