Table of Changes (form)

TABLE OF CHANGES – FORM

Form I-539, Application to Extend/Change Nonimmigrant Status

OMB Number: 1615-0003

09/27/2018

Reason for Revision: Revision to include public benefits questions.

• Black font = Current text

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
New		[Page 3] Part 5. Public Benefits 1. Have you or any derivatives listed on this application EVER applied for or received any public benefits as listed in the instructions? Yes No If you answered “Yes,” 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. 2.a. Type of Benefit 2.b. Amount of Benefit Weekly Monthly Annually Other [fillable field] 2.c. Agency That Granted The Benefit 2.d. Date Benefit Was Granted 2.e. Date Benefit Ended or Expires (mm/dd/yyyy) 2.f. Number of Household Members Receiving the Benefit 3.a. Type of Benefit 3.b. Amount of Benefit Weekly Monthly Annually Other [fillable field] 3.c. Agency That Granted The Benefit [Page 4] 3.d. Date Benefit Was Granted 3.e. Date Benefit Ended or Expires (mm/dd/yyyy) 3.f. Number of Household Members Receiving the Benefit 4.a. Type of Benefit 4.b. Amount of Benefit Weekly Monthly Annually Other [fillable field] 4.c. Agency That Granted The Benefit 4.d. Date Benefit Was Granted 4.e. Date Benefit Ended or Expires (mm/dd/yyyy) 4.f. Number of Household Members Receiving the Benefit 5.a. Do you or any derivative listed on this application anticipate applying for or receiving the public benefits, as listed in the Instructions, in the future in the United States? Yes No 5.b. Provide information you believe is relevant that would explain why you or any derivative listed on this application anticipate applying for or receiving public benefits in the future. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. [Fillable Field]
Pages 3-4, Part 6. Applicant’s Statement, Contact Information, Certification and Signature	[Page 3] Part 5. Applicant's Statement, Contact Information, Certification and Signature NOTE: Select the box for either Item Number 1.a. or 1.b.  If applicable, select the box for Item Number 2. 1.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 [fillable field], 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 [fillable field], who is [] is not [] an attorney or accredited representative, preparing this form for me. 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. 3.a. Applicant's Signature 3.b. Date of Signature (mm/dd/yyyy) [Page 4] Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address	[Page 4] Part 6. Applicant's Statement, Contact Information, Certification and Signature NOTE: Select the box for either Item Number 1.a. or 1.b.  If applicable, select the box for Item Number 2. 1.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 7. has also read to me every question and instruction on this form, as well as my answer to every question, in [fillable field], 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 [fillable field], who is [] is not [] an attorney or accredited representative, preparing this form for me. 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. 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. [Page 5] I authorize the SSA, U.S. Department of Agriculture (USDA), and U.S. Department of Health and Human Services (HHS), the Department of Housing and Urban Development (HUD), and any other 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 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 Government will use it only to review my eligibility for immigration benefits and to enforce immigration laws, and that the Government may disclose the information only as authorized by law. 3.a. Applicant's Signature 3.b. Date of Signature (mm/dd/yyyy) [Page 4] Applicant's Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number 6. Applicant's E-mail Address
Page 4, Part 7. Contact Information, Statement, Certification, and Signature of the Interpreter	[Page 4] Part 6. Contact Information, Statement, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address Interpreter Certification I certify that: I am fluent in English and [fillable field], which is the same language provided in Part 5., Item Number 1.b.; 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. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)	[Page 5] Part 7. Contact Information, Statement, Certification, and Signature of the Interpreter Interpreter's Full Name Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's E-mail Address [Page 6] Interpreter Certification I certify that: I am fluent in English and [fillable field], which is the same language provided in Part 6., Item Number 1.b.; 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 6., 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. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)
Pages 4-5, Part 8. Contact Information, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant	[Page 4] Part 7. Contact Information, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country [Page 5] Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. 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.b. I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends [] does not extend [] beyond the preparation of this form. 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. 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)	[Page 6] Part 8. Contact Information, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Preparer's Full Name Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Fax Number 6. Preparer's E-mail Address 7.a. 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.b. I am an attorney or accredited representative and my representation of the applicant in this case (choose one) extends [] does not extend [] beyond the preparation of this form. 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. 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
new		[Page 7] 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. 1. Family Name (Last Name) Given Name (First Name) Middle Name 2. A-Number (if any) 3. A. Page Number B. Part Number C. Item Number D. [Fillable field] 4. A. Page Number B. Part Number C. Item Number D. [Fillable field] 5. A. Page Number B. Part Number C. Item Number D. [Fillable field] 6. A. Page Number B. Part Number C. Item Number D. [Fillable field]

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