Fillable I-539a Application to Extend/Change Nonimmigrant Status

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I-539a Application to Extend/Change Nonimmigrant Status

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The I-539a Application to Extend/Change Nonimmigrant Status form is 4 pages long and contains:

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Country of origin: US
File type: PDF

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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 02/04/19
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 08/31/2020
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)
Page 1 of 4
►
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
11.a. Country of Passport or Travel Document Issuance
Provide Your Current Passport Information (if different from
Item Number 9.)
Passport Number13.a.
USCIS Online Account Number (if any)14.
►
Part 3. 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 4. 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.
,
13.b. Country of Passport Issuance
13.c.
Passport Expiration Date
(mm/dd/yyyy)
At my request, the preparer named in Part 5.,
,
2.
prepared this form for me based only upon
information I provided or authorized.
11.b.
Passport or Travel Document Expiration Date
(mm/dd/yyyy)
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
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)
Form I-539A 02/04/19
Page 3 of 4
3.h.
3.g. Postal Code
Country
3.f. Province
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)
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.
Part 4. 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 5. 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
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Form I-539A 02/04/19
Page 4 of 4
Part 6. 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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I-539a Application to ExtendChange Nonimmigrant Status

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Completed 16 November 2019

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