I-539a Frm Toc

TABLE OF CHANGES – Form

Form I-539A, Supplemental Information for Application for Extend/Change Nonimmigrant Status

OMB Number: 1615-0003

07/31/2019

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
Page 3, Public Benefits	[Page 1] [New]	[Page 1] Part 3. Public Benefits Provide the requested information and submit documentation, as outlined in the Instructions. 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) [] Yes, I have received or I am certified to receive the following public benefits (select all that apply): [] Any Federal, State, local or tribal cash assistance for income maintenance [] Supplemental Security Income (SSI) [] Temporary Assistance for Needy Families (TANF) [] General Assistance (GA) [] Supplemental Nutrition Assistance Program (SNAP, formerly called “Food Stamps”) [Page 2] [] Section 8 Housing Assistance under the Housing Choice Voucher Program [] Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation) [] Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq. [] Federally-funded Medicaid [] No, I have not received any of the above listed public benefits. [] No, I am not certified to receive any of the above listed 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) 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) C. 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) 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 enlisted in the Armed Forces, or am serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces. [] 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. [] 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. [] 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. [] 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. [] None of the above statements apply to me. [Page 3] 4.a. 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): [] An emergency medical condition. [] For a service under the Individuals with Disabilities Education Act (IDEA). [] Other school-based benefits or services available up to the oldest age eligible for secondary education under state law. [] While you were under the age of 21. [] While you were pregnant or during the 60-day period following the last day of pregnancy. [] None of the above apply to me. 4.b. Provide the applicable dates: From (mm/dd/yyyy) To (mm/dd/yyyy)
Part 3. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature	[Page 2] 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. 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.a. 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.b. The interpreter named in Part 4. read to me every question and instruction on this form and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 5., [Fillable field], prepared this form for me based only upon information I provided or authorized. [Page 2] Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) 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. [New] Applicant’s Signature 6.a. Applicant's Signature 6.b. Date of Signature (mm/dd/yyyy) 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.	[Page 3] 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. 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.a. 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.b. The interpreter named in Part 5. read to me every question and instruction on this form and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. At my request, the preparer named in Part 6., [Fillable field], prepared this form for me based only upon information I provided or authorized. Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) 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. [Page 4] 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 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. Applicant’s Signature 6.a. Applicant's Signature 6.b. Date of Signature (mm/dd/yyyy) 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.
Part 4. Interpreter’s Contact Information, Statement, Certification, and Signature	[Page 2] Part 4. Interpreter’s Contact Information, Statement, Certification, and Signature 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. Interpreter's Full Name 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 Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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. [Page 3] Interpreter’s Signature 7.a Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)	[Page 4] Part 5. Interpreter’s Contact Information, Statement, Certification, and Signature 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. Interpreter's Full Name 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 [Page 5] Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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 Signature 7.a Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)
Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 3] Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant 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. Preparer's Full Name 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 Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer’s Statement 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 extends/does not extend beyond the preparation of this form. 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. Preparer's Certification 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 Signature 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)	[Page 5] Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant 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. Preparer's Full Name 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 Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) Preparer’s Statement 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 extends/does not extend beyond the preparation of this form. 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. Preparer's Certification 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. [Page 6] Preparer’s Signature 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
Part 6. Additional Information	[Page 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. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]	[Page 7] 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. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

1