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

New Class

Still within period of stay

From

/

/

/

S/D to:

/

Place under docket control

Dates:
To

/

/

Applicant interviewed on

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NOT FOR
PRODUCTI
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To be completed by an
Attorney or Accredited
Representative.

Select this box if
Form G-28 is
attached.

Attorney State Bar Number

Attorney or Accredited Representative
USCIS Online Account Number

► 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)
► A-

3.

USCIS Online Account Number
►

U.S. Mailing Address

4.e. State

Ste.

4.f.

Form I-539 Edition 06/09/20

5.e. ZIP Code

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
►

10.

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

4.b. Street Number
and Name

4.d. City or Town

Flr.

(USPS ZIP Code Lookup)

4.a. In Care Of Name

Apt.

Ste.

5.c. City or Town

2.

4.c.

Apt.

Flr.

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 8

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).

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).

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Part 2. Application Type

I am applying for (select only one box):

Part 4. Additional Information About the
Applicant

1.

Reinstatement to student status.

2.

An extension of stay in my current status.

3.a.

A change of status.

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

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

1.a. Passport Number

1.b. Country of Passport Issuance

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

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

Number of people included in this application (select only one
box):
4.

I am the only applicant.

Physical Address Abroad

5.a.

Members of my family are filing this application with
me.

2.a. Street Number
and Name

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

2.b.

Apt.

Ste.

Flr.

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

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 06/09/20

No

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 9. Additional Information to provide an explanation.

Page 2 of 8

10.

Part 4. Additional Information About the
Applicant (continued)
3.

4.

5.

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

6.

Yes

No

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

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

11.

7.a. Acts involving torture or genocide?

Yes

No

7.b. Killing any person?

Yes

No

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?

No

7.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
Have you, or any other individual included on the application,
EVER:

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

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?
Yes

No

Yes

No

If you answered "Yes" to Item Number 13., provide the
following information concerning the removal proceedings in
the space provided in Part 9. Additional Information. Include
the name of the individual in removal proceedings and
information on jurisdiction, date proceedings began, and status
of proceedings.

7.c. Intentionally and severely injuring any person?

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

No

12.

14.

Yes

No

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

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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:

9.

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?

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

No

If you answered "No" to Item Number 14., fully describe how
you are supporting yourself in Part 9. Additional Information.
Include documentary evidence of the source, amount, and basis
for any income.
If you answered "Yes" to Item Number 14., fully describe the
employment in Part 9. 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.

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

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 9. Additional Information.

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

Form I-539 Edition 06/09/20

No

Page 3 of 8

B.

Part 5. Public Benefits
Provide the requested information and submit documentation,
as outlined in the Instructions.
1.

Type of Benefit

Agency That Granted The Benefit

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

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

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

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

(mm/dd/yyyy)

Supplemental Security Income (SSI)

C.

Type of Benefit

Temporary Assistance for Needy Families
(TANF)

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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.

D.

Federally-funded Medicaid

No, I have not received any of the above listed public
benefits.

Agency That Granted The Benefit

No, I am not certified to receive any of the above
listed public benefits.
2.

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

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 9.
Additional Information. Submit documentation 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

Type of Benefit

(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.

(mm/dd/yyyy)

Form I-539 Edition 06/09/20

Page 4 of 8

Part 5. Public Benefits (continued)

1.b.

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 off 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.

The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in

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

At my request, the preparer named in Part 8.

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

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

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4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

None of the above statements apply to me.

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 of age 21.

While you were pregnant or during the 60-day period
following the last day of pregnancy.
None of the above statements apply to me.
4.b. Provide the applicable dates:
From (mm/dd/yyyy)
To (mm/dd/yyyy)

Part 6. Applicant's Statement, Contact
Information, Declaration, 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 I have read
and understand every question and instruction on this
application and my answer to every question.

Form I-539 Edition 06/09/20

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
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 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 application; 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 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.

Page 5 of 8

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

Part 7. 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)

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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

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.

3.g. Postal Code

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.

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.h. Country

Interpreter's Contact Information

Applicant's Signature

6.a. Applicant's Signature

Interpreter's Certification

I certify, under penalty of perjury, that:

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.

Form I-539 Edition 06/09/20

I am fluent in English and

,

which is the same language specified in Part 6., 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.
Page 6 of 8

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

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.

Interpreter's Signature
7.a. Interpreter's Signature

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

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.

Preparer's Certification

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Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

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

2.

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 Business or Organization Name

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.

Preparer's Signature

8.a. Preparer's Signature

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

Apt.

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

Province

3.g. Postal Code
3.h. Country

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

Ste.

Flr.

3.e. ZIP Code

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)

Form I-539 Edition 06/09/20

Page 7 of 8

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 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.

A-Number

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► 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 06/09/20

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