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pdfApplication to Extend/Change Nonimmigrant Status
Page 1 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
CREATE AN IMMIGRATION ACCOUNT You must set up an immigration account to begin the process of creating an
electronic benefit request. The immigration account may be established at the same time or within 30 days prior to
creating the benefit request.
1. Click “Create
a new Account
6. Provide your
preferred greeting
11. Re-enter your
password
2. Have you
read and agree to
the Privacy Act
Statement?
7. Submit your
request
Select password
reset questions
& answers
3. Select an
Account Type:
Applicant
Attorney/Representative
8. Check your
E-mail for
confirmation
9. While in your
E-mail from USCIS,
Click on the link
Enter your registered
E-mail address
Provide your U.S.
Phone Number
Enter your secure PIN
Enter secure PIN
received on your
phone
Your account is
activated.
End of
account
set up
10. Enter your
new password
Select one of the
following
three security
preferences
How would you like to
receive Secure PIN
(SMS/Text or Voice
Message)?
Your account is
activated.
5. Re-enter your
E-mail
address
4. Provide your
E-mail address
End of
account
set up
Provide personal
identity questions
& answers
End of
account
set up
Application to Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 1 INFORMATION ABOUT YOU
1.a. Do you have a
USCIS Account
Identifier?
No
2.b. Do you have an
Alien Registration
Number?
Yes
Yes
1.b. Account
Identifier
2.b. Alien
Registration #
No
3. Your Full Name
Family Name (Last)
Given Name (First)
Middle Name
(If your name has
changed due to
marriage, divorce,
or other reasons,
you must submit
evidence of the
legal name change.)
6. Date of Birth
9. Province of Birth
10. Country of Birth
(If not in the United
States)
11. Gender
(Male or Female)
14. What was your
immigration status
at time of most
recent arrival to the
United States?
15. Place of most
recent arrival into
the United States
(City or Town)
16. Date of most
recent arrival into
the United States
19. Are you currently
a member of the
U.S. Military?
20. Have you used
any other names
other than the
name shown in
Number 3?
4. Physical Address
Street Number
Street Name
Apartment Number
City or Town
State
Zip Code
Province
Postal Code
Country
7. City or Town
of Birth
12. Country of
Citizenship
Page 2 of 11
5. Mailing Address
(If different from
Physical Address)
In Care of Name
Street Number
Street Name or
PO Box
Apartment Number
City or Town
State
Zip Code
Province
Postal Code
Country
8. State of Birth
13. What is your
current immigration
Status?
(See attached
Evidence Chart)
17.a. Do you have an I-94/I-94W/I-95
Arrival-Departure Record Number OR an
entry stamp in your Passport to establish that
you entered under the Visa Waiver Program
Electronic System for Travel Authorization?
Yes
18. Your ArrivalDeparture Record
or entry stamp
placed in your
Passport expires
or expired on:
(Date)
No
21. – 22. If “Yes”
Other Names Used
(Multiple Entries)
24. USCIS must have information from an official governmentissued identity document that belongs to you if you have one. This
identity document must contain a photo. Do you have a governmentissued photo identity document? If “Yes” provide Information from one
form of identity document below. If “No” go to Number 25.
Passport (Country)
Passport Number
Expiration Date
17.b. ArrivalDeparture
Record Number
Yes
Yes
Yes
23. May USCIS
contact you by
other means other
than the U.S.
Postal Service?
Yes
Driver’s License (State)
Driver’s License Number
Expiration Date
Yes
Other ID (Issuer)
ID Number
Expiration Date
E-Mail, Home Phone
Work Phone, Mobile
Phone, SMS Text
25. Explain why
you do not have a
government-issued
photo identity
document.
Go to Part 2
Application to Extend/Change Nonimmigrant Status
Page 3 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 2 BENEFIT REQUEST TYPE
Extension of Stay
If you are applying to
extend your stay or
change your
nonimmigrant status and
your total period of stay
will be 1 year or more,
you are required to
complete and submit
Supplemental Biographic
Information with this
benefit request.
1.a. I am applying for
an extension of stay
in my current status
and I am the only
applicant.
I request that my
current status be
extended until: (Date)
1.b Members of my
family and I are
applying for an
extensions of stay in
our current status
and we are all
seeking the same
benefit.
We request that our
current status be
extended until: (Date)
2.a. I am applying for
a change of status
and I am the only
applicant.
The new
nonimmigrant status I
am requesting is:
Change of Nonimmigrant
Status
2.b. Members of my
family and I are
applying to change
our status and we are
all seeking the same
benefit.
Reinstatement
The new
nonimmigrant status
we are requesting is:
The total number of
people (including me)
in this benefit request
is:
The total number of
people (including me)
in this benefit request
is:
3.a. I am seeking a
reinstatement to
student status.
3.b. Members of my
family and I are
seeking a
reinstatement of
student/student
dependent status.
The total number of
people (including me)
in this benefit request
is:
If you are an F-1 or M-1 student, you must provide supporting documentation to establish:
-Your violation of status was solely due to circumstances beyond your control or that failure to reinstate you
would result in extreme hardship;
-You are or will be pursuing a full course of study;
-You have not been employed without authorization;
-You are not currently in removal proceedings; and
-You have not been out of status for more than 5 months at the time of filing the request
for reinstatement.
Go to Part 3
-You must also provide supporting documentation that demonstrates your ability to pay for your
studies and support yourself while in the United States.
Application to Extend/Change Nonimmigrant Status
Page 4 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 3 ELIGIBILITY INFORMATION
1. Do you currently
have the Form I-94,
I-94W or I-95 issued
to you in your
possession?
You are required to
submit a copy of
the front and back,
of your original
Form I-94, I-94W, or
I-95.
Yes
No
2. Are you filling this
benefit request based
on a Principal Alien's
nonimmigrant status?
If “No” provide the
reason you are
unable to provide
your original Form I94, I-94W, or I-95.
If “Yes” the principal
alien is requesting or
has acquired
nonimmigrant status
through:
3.c. Inspection
and admission
into the United
States in his or
her current
nonimmigrant
status which is:
No
If “No” go to
Part 3,
Number 14
Information about the Principal Alien
4. Gender
5.a. Family Name
5.b. Given Name
5.c. Middle Name
6.a. Street Number
6.b. Street Name
6.c. Apartment Number
6.d. City or Town
6.e. State
6.f . Zip Code
7. Principal Alien's Date of Birth
8. Principal Alien's Country of Birth
9. Principal Alien's Country of Citizenship
10. Principal Alien's USCIS Account Identifier (if any)
11. Principal Alien's I-94/I-94W/I-95 Arrival-Departure Record
Number
12. Principal Alien's A-Number (if any)
3.a. A Form I-129,
Petition for
Nonimmigrant
Worker, that is
being
concurrently filed
with this benefit
request.
3.b. A Form I-129
or Form I-539 that
was previously
filed with USCIS.
Yes
3.b.1. Provide USCIS
Receipt/Case
Number
3.c.1. Provide
nonimmigrant status
13. Relationship to the Principal
Alien
• Spouse
• Step-Child (not married)
• Biological Child (not married)
• Adopted Child (not married)
• Other Dependent Family
Member as designated by the U.S.
Department of State (Explain)
Go to
Part 3,
Number 14
Application to Extend/Change Nonimmigrant Status
Page 5 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 3 ELIGIBILITY INFORMATION (continued)
14. Are you, or any
other person included
in this benefit request
currently in,
requesting a change
to, or requesting
reinstatement to F or
M or J nonimmigrant
status?
Yes
No
If “Yes” provide your
SEVIS Case Number
15.a. Are you a B-2 visitor applying to extend your
stay, or are you applying to change your status to
that of an F-1 or M-1 Student?
Yes
No
Yes
15.b. Name of
person/people who
will provide financial
support:
Family Name (Last)
Given Name (First)
Middle Name
If “Yes” provide the
following information
concerning how you
will support yourself
financially in the
United States in your
requested status.
Complete all that
apply:
15.c. Relationship of
person/people to the
applicant(s) in this
case?
(You must submit
documentation that
demonstrates you
or someone else
has the ability to
pay for your studies
and support you
while you are in the
United States.)
17.a. Are you, or any other
person included in this
benefit request currently an
applicant for an immigrant
visa?
Yes
No
17.b. If “Yes” name of person
included in this benefit
request who filed the
application for the immigrant
visa:
Family Name (Last)
Given Name (First)
Middle Name
17.c. If “Yes” provide the
USCIS Receipt/Case
Number of the immigrant
petition that was filed on your
behalf (if known):
16.a. Are you, or any other
person included in this benefit
request, in a current J1 or J2
nonimmigrant status?
15.d. Amount of
financial support to
be provided per
month:
15.e. Scholarship or
grant from
educational institution
in the amount of:
18.a. To your knowledge, are you, or any
other person included on this benefit
request the beneficiary of any other
nonimmigrant or immigrant application or
petition?
Yes
No
18.b. If “Yes” name of the person included
in this benefit request who is the
beneficiary of another nonimmigrant or
immigrant application or petition:
Family Name (Last)
Given Name (First)
Middle Name
18.c. If “Yes” provide the
USCIS Receipt/Case
Number of the application or
petition (if known):
No
16.b. If “Yes” name of the
person included in this benefit
request who is in J
nonimmigrant status:
Family Name (Last)
Given Name (First)
Middle Name
16.c. Is the person in J
nonimmigrant status subject to
the 2-year foreign residence
requirement?
16.d. If “Yes” has that person
already received a waiver of the
2-year foreign residence
requirement from USCIS?
16.e. If “Yes” provide the USCIS
Receipt/Case Number of the
approved waiver
19.a. 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 benefit request?
Yes
No
19.b. If “Yes” name of the
person included in this
benefit request who filed
the Form I-485:
Family Name (Last)
Given Name (First)
Middle Name
19.c. If “Yes” provide the
USCIS Receipt/Case
Number from the Form
I-485 filed:
Go to
Number
20.a.
Application to Extend/Change Nonimmigrant Status
Page 6 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 3 ELIGIBILITY INFORMATION (continued)
20.a Have you, or any other person
included in this benefit request EVER
been arrested since entering the
United States? PROVIDE A COPY
OF ALL ARREST RECORDS.
Yes
No
If a particular document is unavailable,
you must provide official or certified
evidence from the court confirming the
unavailability of the record.
Have you, or any
person included in
this benefit request
EVER ordered,
incited, called for,
committed,
assisted, helped
with, or otherwise
participated in any
of the following:
23.b. Have you, or any other person
included in this benefit request, EVER
worked in any prison, jail, prison camp,
detention facility, labor camp, or any
other situation that involved detaining
persons?
No
22.e. Engaged in
any kind of sexual
contact or
relations with any
person/people
who were being
forced or
threatened?
22.f. Limited or
denied any
person's ability to
exercise their
religious beliefs?
No
21. Have you, or any
person included in this
benefit request, EVER
been under removal
proceedings?
Yes
No
24. Have you or any
person included in this
benefit request been
employed in the United
States since your or
his or her last entry
into the United States
or the date of your or
his or her last grant of
an extension or
change of status?
Yes
Yes
No
Yes
22.c. Killing any
person/people?
22.d. Intentionally
and severely
injuring any
person/people?
Yes
23.a. Have you, or any other person
included in this benefit request, 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?
22.a. Acts
involving torture?
22.b. Acts involving
genocide?
20.b. If arrested, were you, or any other
person included in this benefit request,
convicted of the offense? PROVIDE A
COPY OF ALL CONVICTION AND
COURT DISPOSITION RECORDS.
23.c. Have you, or any other person
included in this benefit request, 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?
No
25. Have you, or any
other person included
in this benefit request,
remained in the United
States past your or his
or her authorized
period of stay.
Yes
23.d. Have you, or any other person
included in this benefit request, EVER
assisted or participated in selling or
providing weapons to any person who to
your knowledge used them against
another person, or in transporting
weapons to any person who to your
knowledge used them against another
person?
23.e. Have you, or any other person
included in this benefit request, EVER
received any type of military,
paramilitary, or weapons training?
No
If “Yes”
You Must
Complete
Part 8
If you have
beneficiaries
complete
Part 4
Application to Extend/Change Nonimmigrant Status
Page 7 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 4 INFORMATION ABOUT BENEFICIARIES
1.a. Does the
beneficiary have
a USCIS
Account Identifier?
Yes
1.b. Account
Identifier
5. Does this
beneficiary currently
reside with you? If
“Yes” go to
Number 8.
Yes
No
10. Has the
beneficiary
used any other
names other than
the name provided?
No
No
2.a. Does the
beneficiary have an
Alien Registration
Number?
3. Beneficiary’s
Full Name
Family Name (Last)
Given Name (First)
Middle Name
Yes
2.b. Alien
Registration #
6. Beneficiary’s
Physical Address
Street Number
Street Name
Apartment Number
City or Town
State
Zip Code
Province
Postal Code
Country
13. Beneficiary’s
Date of Birth
4. Beneficiary’s Relationship to Applicant or
Petitioner
• Spouse (submit a copy of your marriage
certificate)
• Biological Child (not married) (submit a copy
of child’s birth certificate)
• Adopted Child (not married) (submit a copy of
child’s birth certificate and adoption decree)
• Step-Child (not married) (submit a copy of
child’s birth certificate and a copy of your
marriage certificate.)
• Other Dependent Family Member as
designated by the U.S. Department of State
(Explain)
7. Beneficiary’s
Mailing Address (If
different from
Physical Address)
In Care of Name
Street Number
Street Name or
PO Box
Apartment Number
City or Town
State
Zip Code
Province
Postal Code
Country
14. Beneficiary’s
City or Town
of Birth
8. Beneficiary’s
Country of
Citizenship
9. Beneficiary’s
Gender
(Male or Female)
15. Beneficiary’s
State of Birth
16. Beneficiary’s
Province of Birth
11. – 12. If “Yes”
Other Names Used
(Multiple Entries)
17. Beneficiary’s
Country of Birth
(If not in the United
States)
18. What is the
beneficiary’s current
immigration status?
19. What was the
beneficiary’s
immigration status at
the time of his or her
most recent arrival
into the United States?
22.a. Does the beneficiary have an I-94/I-94W/I-95 Arrival-Departure
Record Number OR an entry stamp in his or her Passport to establish that he or she
entered under the Visa Waiver Program Electronic System for Travel
Authorization? (You are required to submit the original copy, front and
back, of Form I-94/I-94W/I-95 for each person included in this benefit request.)
Yes
22.b. Arrival-Departure
Record Number
20. Beneficiary’s
place of most
recent arrival into
the United States
21. Beneficiary’s
date of most
recent arrival into
the United States
23. The beneficiary’s
Arrival-Departure Record
or entry stamp placed in
his or her Passport expires
or expired on: (Date)
Go to
Part 4,
Number 24
Application to Extend/Change Nonimmigrant Status
Page 8 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 4 INFORMATION ABOUT BENEFICIARIES (continued)
24. USCIS must have information from an official government-issued
identity document. This identity document must contain a photo. Does
the beneficiary have a government-issued photo identity document?
If “Yes” provide information from one form of identity document below.
If “No” go to Number 25.
Yes
Passport (Country)
Passport Number
Expiration Date
Yes
25. Explain why the
beneficiary does not have a
government-issued
photo identity
document.
Yes
Driver’s License (State)
Driver’s License Number
Expiration Date
Other ID (Issuer)
ID Number
Expiration Date
Go to Part 5
PART 5 YOUR SIGNATURE, ATTESTATION, AND REGISTRATION WITH USCIS AT THE TIME OF
FILING THIS BENEFIT REQUEST
The questions on this benefit request
were: (Select one)
1.a. Read by me, or
to me, in the English
language; or
1.b. Translated to me
in the language
below.
SIGNATURE OF APPLICANT OR PETITIONER
3.a. Signature
of Applicant or
Petitioner
3.b. Date of
Signature
1.b.1. Language
to which translated
2. Translation
performed by:
Relative
Neighbor/Friend
Business Associate
Preparer named in
Part 6
Representative
named in Part 6
Other (Explain)
If someone other
than you prepared
this benefit request,
complete Part 6.A.
Application to Extend/Change Nonimmigrant Status
Page 9 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 6 INFORMATION CONCERNING PREPARER AND/OR DESIGNATION OF REPRESENTATION
6.A. PREPARER INFORMATION
USCIS requires the disclosure of any person other than the applicant or petitioner who prepared or assisted in preparing
this benefit request. USCIS does not require disclosure of persons or entities who only transcribed into electronic form the
information provided by the applicant or petitioner, or other disclosed preparers or representatives. (Select one)
1.a. The preparer is NOT an
attorney or Board of Immigration
Appeals (BIA) accredited
representative.
2. Preparer’s Name
Family Name (Last)
Given Name (First)
Middle Name
7. Was the preparer
paid to prepare this
Benefit request?
Yes
No
1.b. The preparer is an attorney
or BIA-accredited representative
who only prepared the benefit
request and WILL NOT be representing
the applicant or petitioner further.
4. Preparer’s
Mailing Address
Street Number
Street Name
Apartment Number
City or Town
State
Zip Code
Province
Postal Code
Country
3. Preparer’s
Business or
Organization Name
8. Does the
preparer have a preexisting relationship
with the applicant
or petitioner?
Yes
No
1.c. The preparer is an attorney or
BIA-Accredited representative
who WILL be representing
the applicant or petitioner
with USCIS. (Complete 6.B.)
5. Preparer’s
Daytime Phone
Number
6. Preparer’s
E-mail Address
SIGNATURE OF PREPARER
9.a. Signature
of Preparer
9.b. Date of
Signature
If “Yes” what type
Of relationship is it?
Relative
Neighbor/Friend
Business Associate
Other (Explain)
If you have an
attorney or accredited
Representative,
complete Part 6.B.
Application to Extend/Change Nonimmigrant Status
Page 10 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 6 INFORMATION CONCERNING PREPARER AND/OR DESIGNATION OF REPRESENTATION (continued)
6.B. DESIGNATION OF REPRESENTATION
Until such time as the authorization is withdrawn or terminated, the applicant or petitioner, by his or her signature, authorizes
USCIS and other agencies of the U.S. Government administering U.S. citizenship and immigration laws to disclose any
information pertaining to the applicant or petitioner in any record or system of records relating to immigration matters to the
representative named, and to his or her law firm or BIA-recognized organization, under the Privacy Act of 1974.
1. Representative’s
Full Name
Family Name (Last)
Given Name (First)
Middle Name
6. Representative’s
Daytime Phone
Number
2. Representative’s
USCIS Account
Identifier
7. Representative’s
E-mail address
3. Representative’s
Business or
Organizational
Name
4. Representative’s
Physical Address
Street Number
Street Name
Apartment Number
City or Town
State
Zip Code
8.a. I am an attorney and a member
in good standing of the bar of the
highest court(s) of the following
state(s), possession(s), territory(ies),
commonwealth(s), or the District
of Columbia.
Bar Memberships
(List States)
5. Representative’s
Mailing Address (If
different from
Physical Address)
Street Number
Street Name or
PO Box
Apartment Number
City or Town
State
Zip Code
I AM NOT subject to any order
of any court or administrative
Agency disbarring, suspending,
enjoining, restraining or otherwise
restricting me in the practice of law.
I AM subject to any order
of any court or administrative
Agency disbarring, suspending,
enjoining, restraining or otherwise
restricting me in the practice of law.
Bar Card
Number(s)
or equivalent
Explain
8.b. I am an accredited representative of the following qualified
non-profit religious, charitable, social service, or similar
organization established in the United States, so recognized by the
Department of Justice, Board of Immigration Appeals
under 8 CFR 292.2.
SIGNATURE OF REPRESENTATIVE
9.a. Signature
of Representative
Accredited
Organization
Name
Representative’s
Accreditation
Date
Organization’s Date
of Accreditation
or Recognition
Representative’s
Accreditation
Expiration Date
9.b. Date of
Signature
SIGNATURE OF APPLICANT OR PETITIONER
10.a. Signature
of Applicant or
Petitioner
10.b. Date of
Signature
Application to Extend/Change Nonimmigrant Status
Page 11 of 11
Department of Homeland Security
U.S. Citizenship and Immigration Services
PART 7 ADDITIONAL INFORMATION ABOUT YOUR CLAIM TO THIS BENEFIT If you require more space to provide any
additional information within this benefit request, please use the space below.
1.a. Part Number
1.c. Free text to
capture information
1.b. Item Number
PART 8 ADDITIONAL INFORMATION COLLECTION FROM PART 3, ELIGIBILITY INFORMATION
If you answered "Yes" to any of the questions in Numbers 20.a. through 25 in Part 3, Eligibility Information, provide the Item
Number you are answering, and answer the corresponding question(s). Please use Number 11 if you wish to provide
additional information than what is requested.
Item Number from
Part 3, Eligibility
Information
1. Full Name of
Person Involved
Family Name (Last)
Given Name (First)
Middle Name
2. Provide your
relationship to the
person involved
3. Alien Registration
Number of person
involved
4. – 7. Where did
the incident occur?
City or Town
State
Province
Country
Relationships
Spouse
Child
Parent
Sibling
None
Other (Explain)
8. Name of entity,
or organization
involved.
9. Provide an
explanation of the
incident, activity, act,
issue, reason, and/or
duties involved.
10.a. – 10.b.
Date and/or time
period involved:
(From – To)
11. Additional
Information
| File Type | application/pdf |
| File Title | Slide 1 |
| Author | dscales |
| File Modified | 2011-03-23 |
| File Created | 2011-03-23 |