Form I-539 Application to Extend/Change Nonimmigrant Status

USCIS
Form I-539

Application to Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0003
Expires 04/30/2018

Action Block

Fee Stamp

For USCIS Use Only
Returned
Resubmitted
Received
Relocated
Sent
Remarks:
Granted

Denied

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New Class

Still within period of stay

From

/

/

/

S/D to:

/

Place under docket control

Dates:

To

/

/

To Be Completed by an Attorney
or Accredited Representative, if any.

Applicant interviewed on

Select this box if G-28 is attached to represent the applicant.
Attorney State License Number:

Part 1. Information About You

Other Information

1.

Alien Registration Number (A-Number)
► A-

6.

Country of Birth

2.

USCIS Online Account Number (if any)
►

7.

Country of Citizenship or Nationality

8.

Date of Birth (mm/dd/yyyy)

9.

U.S. Social Security Number (if any)
►

10.

Date of Last Arrival Into the United States (mm/dd/yyyy)

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

3.c. Middle Name

Mailing Address

(USPS ZIP Code Lookup)

Provide information about your most recent Form I-94

4.a. In Care Of Name

11.a. I-94 Arrival-Departure Record Number
►

4.b. Street Number
and Name
4.c. Apt.

11.b. Passport Number

Ste.

Flr.

11.c. Travel Document Number

4.d. City or Town

11.d. Country of Issuance for Passport or Travel Document

4.e. State

4.f.

ZIP Code
11.e. Expiration Date for Passport or Travel Document

Physical Address

(mm/dd/yyyy)

5.a. Street Number
and Name
5.b. Apt.

12.a. Current Nonimmigrant Status

Ste.

Flr.
12.b. Expiration Date (mm/dd/yyyy)

5.c. City or Town
5.d. State

5.e. ZIP Code

Form I-539 12/23/16 N

12.c.

Check this box if you were granted Duration of Status
(D/S).
Page 1 of 10

Part 2. Application Type (See instructions for fee)

Part 4. Additional Information

I am applying for: (Select one)

If you are the Principal Applicant, provide your current Passport
information:

1.

An extension of stay in my current status.

2.a.

A change of status. The new status and effective date

1.a. Country of Issuance for Passport

of change. (mm/dd/yyyy)
1.b. Expiration Date for Passport (mm/dd/yyyy)

2.b. The change of status I am requesting is:

3.

Foreign Home Address

Reinstatement to student status.

2.a. Street Number
and Name

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Number of people included in this application: (Select one)
4.

I am the only applicant.

5.a.

Members of my family are filing this application with
me.

2.b. Apt.

Ste.

Flr.

2.c. City or Town

5.b. The total number of people (including me) in the
application is: (Complete the supplement for each
co-applicant.)

2.d. Province

Part 3. Processing Information

2.f.

1.a. I/We request that my/our current or requested status be

Answer the following questions. If you answer "Yes" to any
question, describe the circumstances in detail and explain on a
separate sheet of paper.

2.e. Postal Code

extended until (mm/dd/yyyy)
1.b.

Check this box if you were granted, or are seeking,
Duration of Status (D/S).

2.a. Is this application based on an extension or change of
status already granted to your spouse, child, or parent?
Yes

►

3.

Are you, or any other person included on the application,
an applicant for an immigrant visa?
Yes
No

4.

Has an immigrant petition EVER been filed for you or for
any other person included in this application?
Yes
No

5.

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 application?

No

2.b. If "Yes," provide USCIS Receipt Number.

3.a. Is this application based on a separate petition or application
to give your spouse, child, or parent an extension or change
of status?
Yes, filed with this I-539.
No

6.

Yes, filed previously and pending with USCIS.

3.b. If pending with USCIS, provide USCIS Receipt Number
►
If the petition or application is pending with USCIS, also give
the following data:
3.c. First and last name of petitioner or applicant

Date Filed (mm/dd/yyyy)

Form I-539 12/23/16 N

No

Have you, or any other person included in this application,
EVER been arrested or convicted of any criminal offense
since last entering the United States?
Yes
No

7.

Acts involving torture or genocide?

Yes

No

8.

Killing any person?

Yes

No

9.

Intentionally and severely injuring any person?
Yes

10.

3.e. State
3.f.

Yes

Have you, or any other person included on the application,
EVER ordered, incited, called for, committed, assisted, helped
with, or otherwise participated in any of the following:

Office where petition or application filed:
3.d. City or Town

Country

Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes

11.

No

No

Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
Page 2 of 10

20.

Part 4. Additional Information (continued)
12.

Have you, or any other person included on the application,
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?

Yes

13.

14.

15.

Have you, or any other person included in this application,
EVER served in any prison, jail, prison camp, detention
facility, labor camp, or any other situation that involved
detaining persons?
Yes
No

Have you, or any other person 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?

Have you, or any other person included in this application,
EVER received any type of military, paramilitary, or
weapons training?
Yes
No
Have you, or any other person included in this
application, done anything that violated the terms of the
nonimmigrant status you now hold?
Yes
No

18.

Are you, or any other person included in this application,
now in removal proceedings?
Yes
No

If "Yes," provide the following information concerning the
removal proceedings in Part 4. Additional Information for
Answers to Item Numbers 18., 19., and 20. Include the name
of the person in removal proceedings and information on
jurisdiction, date proceedings began, and status of proceedings.

Have you, or any other person included in this
application, been employed in the United States since last
admitted or granted an extension or change of status?
Yes

If "Yes," you must provide the dates you maintained status as a
J-1 exchange visitor or J-2 dependent in Part 4. Additional
Information for Answers to Item Numbers 18., 19. and 20.

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

2.c. Agency That Granted The Benefit

2.d. Date Benefit Was Granted (mm/dd/yyyy)

2.e. Date Benefit Ended or Expires (mm/dd/yyyy)

2.f.

Number of Household Members Receiving the Benefit

3.a. Type of Benefit

No

If "No," fully describe how you are supporting yourself in
Part 4. Additional Information for Answers to Item
Numbers 18., 19., and 20. Include documentary evidence of
the source, amount, and basis for any income.
If "Yes," fully describe the employment in Part 4. Additional
Information for Answers to Item Numbers 18., 19., and 20.
Include the name of the person employed, name and address of
the employer, weekly income, and whether the employment was
specifically authorized by USCIS.

Form I-539 12/23/16 N

No

No

17.

19.

Yes

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Have you, or any other person included in this application,
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?
Yes
No

Yes

16.

No

Are you, or any other person 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?

3.b. Amount of Benefit
Weekly

Monthly

$
Annually

Other
3.c.

Agency That Granted The Benefit

Page 3 of 10

Part 5. Public Benefits (continued)
3.d. Date Benefit Was Granted (mm/dd/yyyy)

3.e. Date Benefit Ended or Expires (mm/dd/yyyy)

3.f.

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

Number of Household Members Receiving the Benefit

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4.a. Type of Benefit

4.b. Amount of Benefit
Weekly
Other

Monthly

,

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.

$

Annually

2.

I have requested the services of and consented to

4.c. Agency That Granted The Benefit

4.d. Date Benefit Was Granted (mm/dd/yyyy)

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.

Form I-539 12/23/16 N

,

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 4 of 10

Part 6. Applicant's Statement, Contact
Information, Certification and Signature
(continued)
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.

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)

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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.

2.

Interpreter's Mailing Address

3.a. Street Number
and Name
3.b. Apt.

3.a. Applicant's Signature

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

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.

Interpreter's Business or Organization Name (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's E-mail Address

3.b. Date of Signature (mm/dd/yyyy)

Applicant's Contact Information
4.

Applicant's Daytime Telephone Number

5.

Applicant's Mobile Telephone Number

6.

Applicant's E-mail Address

Form I-539 12/23/16 N

Page 5 of 10

Part 7. Contact Information, Statement,
Certification, and Signature of the Interpreter
(continued)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

Interpreter Certification
3.c. City or Town

I certify that:
I am fluent in English and
, 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

3.d. State
3.f.

3.e. ZIP Code

Province

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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

3.g. Postal Code
3.h. Country

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

6.b. Date of Signature (mm/dd/yyyy)

5.

Preparer's Fax Number

Part 8. Contact Information, Certification, and
Signature of the Person Preparing this
Application, If Other Than the Applicant

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 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)

Preparer's Certification

2.

Preparer's Business or Organization Name

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)

Form I-539 12/23/16 N

Page 6 of 10

5.a. Page Number

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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

Form I-539 12/23/16 N

4.c. Item Number

7.a. Page Number

7.d.

Page 7 of 10

Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.)

Person Two
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Person One

2.c. Middle Name

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

2.d. Date of Birth (mm/dd/yyyy)
2.e. Country of Birth

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1.c. Middle Name

2.f.

Country of Citizenship or Nationality

1.d. Date of Birth (mm/dd/yyyy)
1.e. Country of Birth

2.g. U.S. Social Security Number (if any)
►

1.f.

2.h. Alien Registration Number (A-Number)

Country of Citizenship or Nationality

► A-

1.g. U.S. Social Security Number (if any)
►

2.i.

Date of Arrival (mm/dd/yyyy)

2.j.

I-94 Arrival/Departure Record Number
►

1.h. Alien Registration Number (A-Number)
► A-

2.k. Passport Number

1.i.

Date of Arrival (mm/dd/yyyy)

1.j.

I-94 Arrival/Departure Record Number
►

2.l.

Travel Document Number

2.m. Country of Issuance for Passport or Travel Document

1.k. Passport Number
1.l.

Travel Document Number

2.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

1.m. Country of Issuance for Passport or Travel Document

2.o. Current Nonimmigrant Status

1.n. Expiration Date for Passport or Travel Document

2.p. Expiration Date (mm/dd/yyyy)

(mm/dd/yyyy)

1.o. Current Nonimmigrant Status

1.p. Expiration Date (mm/dd/yyyy)

Form I-539 12/23/16 N

Page 8 of 10

Person Four

Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.) (continued)

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

Person Three

4.c. Middle Name

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

4.d. Date of Birth (mm/dd/yyyy)
4.e. Country of Birth

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3.c. Middle Name

4.f.

Country of Citizenship or Nationality

3.d. Date of Birth (mm/dd/yyyy)
3.e. Country of Birth

4.g. U.S. Social Security Number (if any)
►

3.f.

4.h. Alien Registration Number (A-Number)

Country of Citizenship or Nationality

► A-

3.g. U.S. Social Security Number (if any)
►

4.i.

Date of Arrival (mm/dd/yyyy)

4.j.

I-94 Arrival/Departure Record Number
►

3.h. Alien Registration Number (A-Number)
► A-

4.k. Passport Number

3.i.

Date of Arrival (mm/dd/yyyy)

3.j.

I-94 Arrival/Departure Record Number
►

4.l.

Travel Document Number

4.m. Country of Issuance for Passport or Travel Document

3.k. Passport Number
3.l.

Travel Document Number

4.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

3.m. Country of Issuance for Passport or Travel Document

4.o. Current Nonimmigrant Status

3.n. Expiration Date for Passport or Travel Document

4.p. Expiration Date (mm/dd/yyyy)

(mm/dd/yyyy)

3.o. Current Nonimmigrant Status

3.p. Expiration Date (mm/dd/yyyy)

Form I-539 12/23/16 N

Page 9 of 10

Person Six

Supplement A. Attach to Form I-539 when more
than one person is included in this application.
(List each person separately. Do not include the
person named in Form I-539.) (continued)

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

Person Five

6.c. Middle Name

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

6.d. Date of Birth (mm/dd/yyyy)
6.e. Country of Birth

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5.c. Middle Name

6.f.

Country of Citizenship or Nationality

5.d. Date of Birth (mm/dd/yyyy)
5.e. Country of Birth

6.g. U.S. Social Security Number (if any)
►

5.f.

6.h. Alien Registration Number (A-Number)

Country of Citizenship or Nationality

► A-

5.g. U.S. Social Security Number (if any)
►

6.i.

Date of Arrival (mm/dd/yyyy)

6.j.

I-94 Arrival/Departure Record Number
►

5.h. Alien Registration Number (A-Number)
► A-

6.k. Passport Number

5.i.

Date of Arrival (mm/dd/yyyy)

5.j.

I-94 Arrival/Departure Record Number
►

6.l.

Travel Document Number

6.m. Country of Issuance for Passport or Travel Document

5.k. Passport Number
5.l.

Travel Document Number

6.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

5.m. Country of Issuance for Passport or Travel Document

6.o. Current Nonimmigrant Status

5.n. Expiration Date for Passport or Travel Document

6.p. Expiration Date (mm/dd/yyyy)

(mm/dd/yyyy)

5.o. Current Nonimmigrant Status

5.p. Expiration Date (mm/dd/yyyy)

Form I-539 12/23/16 N

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