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pdfSupplemental Information for Application to
Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
To be completed by an
attorney or BIAaccredited
representative (if any).
Select this box if
Form G-28 is
attached.
Attorney State Bar Number
(if applicable)
USCIS
Form I-539A
OMB No. 1615-0003
Expires 10/31/2021
Attorney or Accredited Representative
USCIS Online Account Number (if any)
► START HERE - Type or print in black ink.
Part 1. Information About the Person Filing
Form I-539
11.a. Country of Passport or Travel Document Issuance
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
11.b. Passport or Travel Document Expiration Date
1.c. Middle Name
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(mm/dd/yyyy)
12.a. Current Nonimmigrant Status
Part 2. Information About You
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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
13.b. Country of Passport Issuance
13.c. Passport Expiration Date
(mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)
3.
Country of Birth
4.
Country of Citizenship or Nationality
5.
U.S. Social Security Number (if any)
►
6.
Alien Registration Number (A-Number) (if any)
► ADate of Arrival (mm/dd/yyyy)
Provide Information About Your Most Recent Entry Into the
United States
8.
Provide Your Current Passport Information (if different from
Item Number 9.)
13.a. Passport Number
2.
7.
12.b. Expiration Date (mm/dd/yyyy)
Form I-94 Arrival-Departure Record Number
►
9.
Passport Number
10.
Travel Document Number
14.
USCIS Online Account Number (if any)
►
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 5. read to me every
question and instruction on this form and my answer
to every question in
,
Form I-539A Edition 06/09/20
a language in which I am fluent, and I understood
everything.
Page 1 of 4
Applicant's Signature
Part 3. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
2.
6.a. Applicant's Signature
At my request, the preparer named in Part 6.,
,
prepared this form for me based only upon
information I provided or authorized.
Applicant's Contact Information
3.
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.
Applicant's Daytime Telephone Number
Part 4. Interpreter's Contact Information,
Statement, Certification, and Signature
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4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
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
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.
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.
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
(USPS ZIP Code Lookup)
3.a. Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
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 Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
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.
Form I-539A Edition 06/09/20
Page 2 of 4
Part 4. Interpreter's Contact Information,
Statement, Certification, and Signature
(continued)
Preparer's Contact Information
Interpreter's Certification
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (if any)
I certify, under penalty of perjury, that:
I am fluent in English and
,
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.
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.
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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
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 Statement
Preparer's Business or Organization Name
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
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
8.b. Date of Signature (mm/dd/yyyy)
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
3.e. ZIP Code
Province
3.g. Postal Code
3.h. Country
Form I-539A Edition 06/09/20
Page 3 of 4
5.a. Page Number
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.
5.b. Part Number
5.c. Item Number
5.d.
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A-Number (if any)
► A-
6.a. Page Number
3.a. Page Number
3.b. Part Number
6.b. Part Number
6.c. Item Number
7.b. Part Number
7.c. Item Number
3.c. Item Number
6.d.
3.d.
7.a. Page Number
4.a. Page Number
4.b. Part Number
4.c. Item Number
7.d.
4.d.
Form I-539A Edition 06/09/20
Page 4 of 4
File Type | application/pdf |
File Title | I-539A, Supplemental Information for Application to Extend/Change Nonimmigrant Status |
Author | USCIS |
File Modified | 2020-08-05 |
File Created | 2020-08-05 |