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

Supplemental 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.

Select this box if
Form G-28 is
attached.

Attorney State Bar Number

USCIS
Form I-539A
OMB No. 1615-0003
Expires 10/31/2021

Attorney or Accredited Representative
USCIS Online Account Number

► 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

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(mm/dd/yyyy)

12.a. Current Nonimmigrant Status

1.c. Middle Name

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

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)

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

13.b. Country of Passport Issuance

1.c. Middle Name

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

2.

Date of Birth (mm/dd/yyyy)

14.

3.

Country of Birth

4.

Country of Citizenship or Nationality

USCIS Online Account Number
►

Part 3. Public Benefits

Provide the requested information and submit documentation,
as outlined in the Instructions.

5.

U.S. Social Security Number
►

6.

Alien Registration Number (A-Number)
► A-

7.

Date of Arrival (mm/dd/yyyy)

Provide Information About Your Most Recent Entry Into the
United States
8.

Form I-94 Arrival-Departure Record Number
►

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)

9.

Passport Number

General Assistance (GA)

10.

Travel Document Number

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

Form I-539A Edition 06/09/20

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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

Part 3. Public Benefits (continued)
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.

Type of Benefit

Federally-funded Medicaid
No, I have not received any of the above public
benefits.

Agency That Granted The Benefit

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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 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

(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 and I
received the public benefits during that time.
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.

Agency That Granted The Benefit

Form I-539A Edition 06/09/20

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Part 3. Public Benefits (continued)

Applicant's Contact Information

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):

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

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.

Applicant's Certification

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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:

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.

From (mm/dd/yyyy)
To (mm/dd/yyyy)

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:

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

1) I reviewed and understood all of the information
contained in, and submitted with, my form; and

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

2) All of this information was complete, true, and correct
at the time of filing.

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

,

At my request, the preparer named in Part 6.,

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

Form I-539A Edition 06/09/20

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

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

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

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

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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.

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)

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 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

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.

Interpreter's 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.

7.a. Interpreter's Signature

Interpreter's Full Name

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

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)

Form I-539A Edition 06/09/20

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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)

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.

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

Preparer's Certification

2.

Preparer's Business or Organization Name

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

Apt.

Ste.

Flr.

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.

3.c. City or Town

Preparer's Signature

3.d. State
3.f.

Province

3.e. ZIP Code

3.g. Postal Code
3.h. Country

8.a. Preparer's Signature

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

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-539A Edition 06/09/20

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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 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

3.a. Page Number

3.d.

4.a. Page Number

► A-

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.d.

Form I-539A Edition 06/09/20

4.c. Item Number

7.a. Page Number

7.d.

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