Form I-539A Supplemental Information for Application to Extend/Chang

Supplemental Information for Application to
Extend/Change Nonimmigrant Status

USCIS
Form I-539A

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)

OMB No. 1615-0003
Expires 08/31/2020

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

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

12.a. Current Nonimmigrant Status

1.c. Middle Name

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

Part 2. Information About You

Provide Your Current Passport Information (if different from
Item Number 9.)

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.

13.b. Country of Passport Issuance

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

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

1.c. Middle Name

13.a. Passport Number

14.

2.

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)

USCIS Online Account Number (if any)
►

Part 3. Biographic Information

1.

Ethnicity (Select only one box)
Hispanic or Latino

Not Hispanic or Latino

2.

American Indian or Alaska Native
Asian

► A-

7.

Race (Select all applicable boxes)

Black or African American

Date of Arrival (mm/dd/yyyy)

Native Hawaiian or Other Pacific Islander

Provide Information About Your Most Recent Entry Into the
United States

White
3.

Height

Form I-94 Arrival-Departure Record Number
►

4.

Weight

9.

Passport Number

5.

Eye Color (Select only one box)

10.

Travel Document Number

8.

11.a. Country of Passport or Travel Document Issuance

Form I-539A 02/04/19

Feet

Inches
Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other
Page 1 of 4

Part 3. Biographic Information

Applicant's Declaration and Certification

6.

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.

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

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

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.

Part 4. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature

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.

NOTE: Read the Penalties section of the Form I-539 and
Form I-539A Instructions before completing this section.

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Applicant's Statement

Applicant's Signature

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

6.a. Applicant's Signature

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

,

a language in which I am fluent, and I understood
everything.
2.

,

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

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 5. Interpreter's Contact Information,
Statement, Certification, and Signature

At my request, the preparer named in Part 6.,
prepared this form for me based only upon
information I provided or authorized.

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

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)

4.

Applicant's Mobile Telephone Number (if any)
1.b. Interpreter's Given Name (First Name)

5.

Applicant's Email Address (if any)
2.

Form I-539A 02/04/19

Interpreter's Business or Organization Name (if any)

Part 5. Interpreter's Contact Information,
Statement, Certification, and Signature
(continued)

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

Interpreter's Mailing Address

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.

(USPS ZIP Code Lookup)

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

Apt.

Ste.

Preparer's Full Name

Flr.

1.a. Preparer's Family Name (Last Name)
3.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

1.b. Preparer's Given Name (First Name)

Province
2.

3.g. Postal Code
3.h. Country

Preparer's Business or Organization Name

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Preparer's Mailing Address

3.a. Street Number
and Name

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

3.b.

Apt.

Flr.

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

6.

Ste.

Interpreter's Email Address (if any)

3.f.

3.e. ZIP Code

Province

3.g. Postal Code

Interpreter's Certification

3.h. Country

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 Declaration and
Certification, and has verified the accuracy of every answer.

Interpreter's Signature

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)

7.a. Interpreter's Signature

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

Form I-539A 02/04/19

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Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
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.

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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)

Form I-539A 02/04/19

Page 3 of 4

5.a. Page Number

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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

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A-Number (if any)
► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-539A 02/04/19

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

4.c. Item Number

7.a. Page Number

7.d.

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