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 10/31/2021

Action Block

Fee Stamp

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

Denied

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NOT FOR
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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).

/

/

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

Applicant interviewed on

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

U.S. Physical Address

Your Full Name

5.a. Street Number
and Name

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

5.b.

1.c. Middle Name

5.d. State

Alien Registration Number (A-Number) (if any)
► A-

3.

USCIS Online Account Number (if any)
►

U.S. Mailing Address

Flr.

Other Information About You

6.

Country of Birth

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)

4.b. Street Number
and Name
Ste.

5.e. ZIP Code

(USPS ZIP Code Lookup)

4.a. In Care Of Name (if any)

Apt.

Ste.

5.c. City or Town

2.

4.c.

Apt.

Flr.

4.d. City or Town
4.e. State

4.f.

Form I-539 Edition 10/15/19

ZIP Code

Provide Information About Your Most Recent Entry Into the
United States
11.

Form I-94 Arrival-Departure Record Number
►

12.

Passport Number

Page 1 of 9

2.b. If you answered "Yes" to Item Number 2.a., provide
USCIS Receipt Number.
►

Part 1. Information about You (continued)
13.

Travel Document Number

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

14.a. Country of Passport or Travel Document Issuance

14.b. Passport or Travel Document Expiration Date
(mm/dd/yyyy)

Yes, filed previously and pending with U.S.
Citizenship and Immigration Services (USCIS).

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15.a. Current Nonimmigrant Status (e.g. F-1 student, H-4
dependent, etc.)

3.b. If pending with USCIS, provide USCIS Receipt Number.
►

15.b. Expiration Date (mm/dd/yyyy)

If the petition or application is pending with USCIS, also
provide the following information:

16.

4.

First and Last Name of Petitioner or Applicant

5.

Date Filed (mm/dd/yyyy)

Select this box if you were granted Duration of Status
(D/S).

Part 2. Application Type

I am applying for (select only one box):

Part 4. Principal Applicant's Biographic
Information

1.

Reinstatement to student status.

2.

An extension of stay in my current status.

3.a.

A change of status.

1.

Ethnicity (Select only one box)
Hispanic or Latino

3.b. New status and effective date of change (mm/dd/yyyy)

2.

Not Hispanic or Latino

Race (Select all applicable boxes)

American Indian or Alaska Native

3.c. The change of status I am requesting is:

Asian

Black or African American

Number of people included in this application (select only one
box):

Native Hawaiian or Other Pacific Islander

4.

I am the only applicant.

White

5.a.

Members of my family are filing this application with
me.

5.b. The total number of people (including me) in the
application is: (Complete Form I-539A for each
co-applicant.)

3.

Height

4.

Weight

5.

Eye Color (Select only one box)

Part 3. Processing Information
1.

I/We request that my/our current or requested status be
extended until (mm/dd/yyyy):

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

Form I-539 Edition 10/15/19

No

6.

Feet

Inches

Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

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Part 5. Additional Information About the
Applicant

7.c. Intentionally and severely injuring any person?

Provide Your Current Passport Information (if different from
Part 1.)

7.d. Engaging in any kind of sexual contact or relations with
any person who did not consent or was unable to consent,
or was being forced or threatened?
Yes
No

Yes

1.a. Passport Number

No

7.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

1.b. Country of Passport Issuance

Have you, or any other individual included on the application,
EVER:

1.c. Passport Expiration Date (mm/dd/yyyy)

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8.a. Served in, been a member of, assisted, or participated in any
military unit, paramilitary unit, police unit, self-defense unit,
vigilante unit, rebel group, guerrilla group, militia, insurgent
organization, or any other armed group?
Yes
No

Physical Address Abroad
2.a. Street Number
and Name
2.b.

Apt.

Ste.

8.b. Worked, volunteered, or otherwise served in any prison,
jail, prison camp, detention facility, labor camp, or any
other situation that involved detaining persons?

Flr.

2.c. City or Town
2.d. Province

9.

2.e. Postal Code
2.f.

Country

Answer the following questions. If you answer “Yes” to any of
the questions in Item Numbers 3. - 15., use the space provided
in Part 10. Additional Information to provide an explanation.
3.

4.

5.

Are you, or any other individual included on the
application, an applicant for an immigrant visa?
Yes

11.

Has an immigrant petition EVER been filed for you or for
any other individual included in this application?
Yes
No
Has Form I-485, Application to Register Permanent
Residence or Adjust Status, EVER been filed by you or
by any other individual included in this application?
Yes

6.

No

10.

No

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

Have you, or any other individual included on the application,
EVER ordered, incited, called for, committed, assisted, helped
with, or otherwise participated in any of the following:
7.a. Acts involving torture or genocide?

Yes

No

7.b. Killing any person?

Yes

No

Yes

Have you, or any other individual included in this
application, EVER been a member of, assisted, 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

Have you, or any other individual 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?
Yes

No

Have you, or any other individual included in this
application, EVER received any type of military,
paramilitary, or weapons training?
Yes

No

12.

Have you, or any other individual included in this
application, done anything that violated the terms of the
nonimmigrant status you now hold?
Yes
No

13.

Are you, or any other individual included in this
application, now in removal proceedings?
Yes

No

If you answered "Yes" to Item Number 13., provide the
following information concerning the removal proceedings in
the space provided in Part 10. Additional Information.
Include the name of the individual in removal proceedings and
information on jurisdiction, date proceedings began, and status
of proceedings.
14.

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

Form I-539 Edition 10/15/19

No

No
Page 3 of 9

Part 5. Additional Information About the
Applicant (continued)
If you answered "No" to Item Number 14., fully describe how
you are supporting yourself in Part 10. Additional
Information. Include documentary evidence of the source,
amount, and basis for any income.

2.

If you have 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
10. Additional Information. Submit documentation as
outlined in the Instructions.
A.

If you answered "Yes" to Item Number 14., fully describe the
employment in Part 10. Additional Information. Include the
name of the individual employed, name and address of the
employer, weekly income, and whether the employment was
specifically authorized by USCIS.
15.

Type of Benefit

Agency That Granted The Benefit

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Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts

Are you, or any other individual 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?
Yes
No

(mm/dd/yyyy)

Date Benefit or Coverage Ended or Expires

If you answered "Yes" to Item Number 15., you must provide
the dates you maintained status as a J-1 exchange visitor or J-2
dependent in Part 10. Additional Information.

(mm/dd/yyyy)

B.

Type of Benefit

Part 6. Public Benefits

Agency That Granted The Benefit

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)

Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts
(mm/dd/yyyy)

Yes, I have received or I am currently certified to
receive the following public benefits:

Any Federal, State, local or tribal cash assistance
for income maintenance

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

C.

Type of Benefit

Supplemental Security Income (SSI)

Temporary Assistance for Needy Families
(TANF)

Agency That Granted The Benefit

General Assistance (GA)
Supplemental Nutrition Assistance Program
(SNAP, formerly called “Food Stamps”)

Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts

Section 8 Housing Assistance under the Housing
Choice Voucher Program

(mm/dd/yyyy)

Section 8 Project-Based Rental Assistance
(including Moderate Rehabilitation)

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

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.
Form I-539 Edition 10/15/19

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Part 6. Public Benefits (continued)
D.

Type of Benefit

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.

Agency That Granted The Benefit

For a service under the Individuals with Disabilities
Education Act (IDEA).
Date You Started Receiving the Benefit or if
Certified, Date You Will Start Receiving the
Benefit or Date Your Coverage Starts

Other school-based benefits or services available up
to the oldest age eligible for secondary education
under state law.

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(mm/dd/yyyy)

While you were under the of age 21.

Date Benefit or Coverage Ended or Expires

While you were pregnant or during the 60-day period
following the last day of pregnancy.

(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.

None of the above statements apply to me.

4.b. Provide the applicable dates:
From (mm/dd/yyyy)

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.

To (mm/dd/yyyy)

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.

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature

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.

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.

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.

1.a.

I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.

1.b.

The interpreter named in Part 8. read to me every
question and instruction on this application and my
answer to every question in

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.

,

a language in which I am fluent, and I understood
everything.

2.

At my request, the preparer named in Part 9.

,
prepared this application for me based only upon
information I provided or authorized.

None of the above statements apply to me.

Applicant's Contact Information

Form I-539 Edition 10/15/19

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

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Part 7. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
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 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

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I furthermore authorize release of information contained in this
application, 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 certify, under penalty of perjury, that all of the information in
my application 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
application and that all of this information is complete, true, and
correct.

Federal Agency Disclosure and Authorizations

I authorize, as applicable, 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, as applicable, the SSA, U.S. Department of
Agriculture (USDA), U.S. Department of Health and Human
Services (HHS), 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, as applicable, 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.

Form I-539 Edition 10/15/19

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

NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.

Part 8. Interpreter's Contact Information,
Statement, Certification, and Signature

Provide the following information about the interpreter.

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.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Page 6 of 9

Preparer's Mailing Address

Part 8. Interpreter's Contact Information,
Statement, Certification, and Signature
(continued)

3.a. Street Number
and Name

Interpreter's Contact Information

3.b.

4.

3.c. City or Town

Interpreter's Daytime Telephone Number

Apt.

3.d. State
5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.f.

Ste.

Flr.

3.e. ZIP Code

Province

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3.g. Postal Code
3.h. Country

Interpreter's Certification

Preparer's Contact Information

I certify, under penalty of perjury, that:
I am fluent in English and

,

which is the same language specified in Part 7., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
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 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.

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 application 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 application.

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
application.

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

Form I-539 Edition 10/15/19

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Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.

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Preparer's Signature
8.a. Preparer's Signature

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

Form I-539 Edition 10/15/19

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5.a. Page Number

Part 10. 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-

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-539 Edition 10/15/19

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