Form I-539A, Supplemental Information for Application to Extend/Change Nonimmigrant Status

Instructions for Supplement A to Form I-539
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-539

OMB No. 1615-0003
Expires 10/31/2021

NOTE: You can complete and file Form I-539 online at www.uscis.gov/I-539 and save $10.
What Is the Purpose of This Form?

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I-539A is part of Form I-539. If you are applying for more than one person using your I-539 application, use a separate
Form I-539A to provide all of the requested information for each additional applicant listed. Each Form I-539A must
include the signature of the individual applicant. If you are under 14 years of age, your parent or legal guardian may sign
the application on your behalf. A legal guardian may also sign for a mentally incompetent person.

Special Instructions for V Nonimmigrants

If you are physically present in the United States and are applying for V nonimmigrant status, see the Who Is Eligible for
V Nonimmigrant Status section below.
NOTE: If you are filing Form I-539A, you do not necessarily have to be in valid nonimmigrant status to obtain V
nonimmigrant status in the United States. See the Who Is Eligible for V Nonimmigrant Status section for more
information.

Who Is Eligible for V Nonimmigrant Status?

To be eligible for V nonimmigrant status, you must be the spouse or child of a lawful permanent resident and be the
beneficiary of a properly filed Form I-130, Petition for Alien Relative, filed on or before December 21, 2000. In addition,
Form I-130 must have been filed three or more years prior to the date of filing Supplement A to Form I-539, and be:
1. Still pending; or

2. Approved, and your beneficiary must either:

A. Wait for an immigrant visa number to become available; or
B. If the visa number is immediately available, you must have pending an application for adjustment of status or an
application for an immigrant visa.
In addition, you must be admissible to the United States, except where the grounds of inadmissibility do not apply or have
been waived. The grounds of inadmissibility that do not apply are Immigration and Nationality Act (INA) sections:
1. 212(a)(6)(A) -- Aliens present without admission or parole;
2. 212(a)(7) -- Aliens without valid passports, visas, or other entry documents; and
3. 212(a)(9)(B) -- Aliens who were unlawfully present for more than 180 days, then departed, and seek admission while
barred from doing so.
Additional Instructions
1. Select Part 2. Application Type, Item Number 3.a. of Form I-539, and indicate “V” in Item Number 3.c.
2. Use information from the qualifying Form I-130 for your response to Part 3., Item Number 3.a. of Form I-539.

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Additional Evidence Requirements for V Nonimmigrants
In addition to the General Filing Instructions and Initial Evidence required by the Form I-539 Instructions, you must
submit:
1. Form I-693, Report of Medical Examination and Vaccination Record, without the vaccination supplement; and
2. Proof of filing of the immigrant petition that qualifies you for V nonimmigrant status, and if necessary, proof of filing
of Form I-485, Application to Register Permanent Residence or Adjust Status. Proof of filing may be in the form of
Form I-797, Notice of Action, that serves as a receipt or as a notice of approval, or a receipt for a filed Form I-130 or
Form I-485, or notice of approval issued by a local district/field office.
If you do not have such proof, USCIS will review other forms of evidence, such as correspondence to or from USCIS
regarding a pending petition.

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If you do not have any of the above items, but believe you are eligible for V nonimmigrant status, you must state where and
when the petition was filed, the name and alien registration number of the petitioner, and the names of all beneficiaries.
Part 3. Public Benefits

In general, as a condition on the approval of this application, you must demonstrate that you have not received since
obtaining the nonimmigrant status you seek to extend or from which you seek to change, one or more public benefits set
forth in 8 CFR 212.21(b) (and listed below) for more than 12 months within any 36 month period (such that, for instance,
receipt of two benefits in one month counts as two months).
You must provide information about all public benefits, as defined in 8 CFR 212.21(b) (and which are listed below), you
have received since obtaining the nonimmigrant status you seek to extend or from which you seek to change. You do not
need to provide information on your receipt of public benefits if you are filing under one of these categories: A1, A2, G1,
G2, G3, G4, NATO1, NATO2, NATO3, NATO4, NATO5, NATO6, NATO7, T1, T2, T3, T4, T5, T6, U1, U2, U3, U4, U5).
Receipt means when a benefit-granting agency provides a public benefit to you whether in the form of cash, voucher,
services, or insurance coverage. Only the public benefits received by or attributable to you will be considered.
In the space provided, please provide all requested information about each public benefit received, regardless of how
long you received the public benefit. USCIS will calculate the duration you received public benefits, as described below,
for purposes of determining your eligibility for an extension of stay or change of status. If you received public benefits
intermittently throughout the year, provide each instance separately. For example, if you received SNAP from January to
February and from June to December, list the information separately. If you need extra space to complete this section, use
the space provided in Part 7. Additional Information.
Indicate whether, since obtaining the nonimmigrant status you seek to extend or from which you seek to change, or
have been certified to receive, any of the following public benefits (You must respond even if you fall within one of the
categories of individuals for whom receipt of public benefits will not be considered – see table below for evidence that
must be provided to document that you qualify for the exclusion):
1. Any Federal, state, local, or tribal cash assistance for income maintenance;
2. Supplemental Security Income (SSI);
3. Temporary Assistance for Needy Families (TANF);
4. Federal, state, or local cash benefit programs for income maintenance (often called “General Assistance” in the state
context, but which may exist under other names);
5. Supplemental Nutrition Assistance Program (SNAP, formerly called “Food Stamps”);
6. Section 8 Housing Assistance under the Housing Choice Voucher Program;
7. Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation);
8. Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.;
9. Federally-funded Medicaid.
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NOTE: You need only to report public benefits received on or after October 15, 2019 but not any received before
October 15, 2019.
If you have not received any of the above listed public benefits, please check that option.
If you are not certified to receive any of the above listed public benefits, please check that option.
If you have received or are certified to receive the public benefits but requested disenrollment, please provide, in addition
to providing the information about any exclusions below, evidence your disenrollment or your request to disenroll if the
public benefit-granting agency has not processed your request.
Unless you qualify for certain exclusions listed in the table below, you are ineligible for extension of stay and change of
status if you have received, since obtaining the nonimmigrant status that you seek to extend or from which you seek to
change, the benefits listed above for more than 12 months in the aggregate within any 36-month period (such that, for
instance, receipt of two public benefits in one month counts as two months).

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The following is a list of exclusions from the public benefit receipt considerations listed above. If you belong to one of
the following categories, submit the evidence listed below for the applicable categories.
Exclusion

U.S. Armed Forces Service Members

Federal-funded Medicaid

Form I-539 Supplement A Instructions 06/09/20

Description

At the time the public benefit was
received or at the time you file
your Form I-539A, or at the time of
adjudication of your Form I-539, you
are:

Evidence you must submit to
qualify for exclusion (as applicable)
•

Service Members: Certified
evidence of alien’s enlistment/
service issued by the authorizing
official of the executive
department in which service
member is serving.

•

Spouses and Children of Service
Members: Copy of Form DD1173, United States Uniformed
Services Identification and
Privilege Card (Dependent).

•

An alien enlisted in the U.S.
Armed Forces, or serving in
active duty or in the Ready
Reserve component of the U.S.
Armed Forces; or

•

The spouse or child of the service
member (listed above).

•

The spouse or child of an
individual enlisted in the U.S.
Armed Forces, or serving in
active duty or in the Ready
Reserve component of the U.S.
Armed Forces.

•

Receipt by an alien under 21 years •
of age;

•

The recipient of Medicaid
payment(s) for an “emergency
medical condition;”

•

The receipt of Medicaid for
services provided under the
Individuals with Disabilities
Education Act (IDEA); or

•

Documentation of payments made
under the IDEA or school-based
service;
A statement with information
regarding the “emergency medical
condition” determination;

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Description

Evidence you must submit to
qualify for exclusion (as applicable)

•

The receipt of Medicaid for
school-based non-emergency
benefits for children who are of
an age eligible for secondary
education as determined under
state law; or

•

•

Receipt during pregnancy and
during the 60-day period after the
last day of the pregnancy.

Children Who Will Naturalize under
INA 322

•

Child currently residing abroad
who entered the United States
with a nonimmigrant visa to
attend N-600K, Application
for Citizenship and Issuance of
Certificate Under INA Section
322 interview.

•

A copy of the N-600K interview
notice.

Public Benefits While in an
Immigration Category Exempt from
Public Charge

•

Received public benefits while
in a category that is exempt from
public charge inadmissibility; or

•

•

Received public benefits while
in a category for which you had
received a waiver for public
charge inadmissibility.

Information that evidences
your status or that you received
a waiver for the public charge
ground of inadmissibility, such as:

Exclusion

Documentation

Pregnancy verification letter from
medical professional including
estimated duration of pregnancy.

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•

Approval notice (Form I-797,
Notice of Action); or

•

Form I-94, Arrival/Departure
Record.

If you have received or are currently certified to receive any of the public benefits listed above, submit evidence in the
form of a letter, notice, certification, or other agency documents that contain the following:
1. Your name;
2. Name and contact information for the public benefit-granting agency;
3. Type of benefit;
4. Date You started receiving the benefit or if certified, date you will start receiving the benefit; and
5. Date benefit or coverage ended or expires (mm/dd/yyy).
If you have received or are currently certified to receive public benefits, please indicate whether an exclusion applies to
you in Item Number 3., and provide the evidence listed in the chart above to demonstrate why the benefit should not be
considered.
In you need extra space to complete this section, use the space provided in Part 7. Additional Information.

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What Is the Filing Fee?
There is no filing fee for Form I-539A.
The filing fee for Form I-539 is $400.
NOTE: The filing fee is not refundable, regardless of any action USCIS takes on this application. DO NOT MAIL
CASH. You must submit all fees in the exact amounts.
Use the following guidelines when you prepare your check or money order for the Form I-539 filing fee:
1. The check or money order must be drawn on a bank or other financial institution located in the United States and must
be payable in U.S. currency; and

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2. Make the check or money order payable to U.S. Department of Homeland Security.

NOTE: Spell out U.S. Department of Homeland Security; do not use the initials “USDHS” or “DHS.”
Notice to Those Making Payment by Check. If you send us a check, USCIS will convert it into an electronic funds
transfer (EFT). This means we will copy your check and use the account information on it to electronically debit your
account for the amount of the check. The debit from your account will usually take 24 hours and your bank will show it
on your regular account statement.
You will not receive your original check back. We will destroy your original check, but will keep a copy of it. If USCIS
cannot process the EFT for technical reasons, you authorize us to process the copy in place of your original check. If your
check is returned as unpayable, USCIS will re-submit the payment to the financial institution one time. If your check is
returned as unpayable, we may reject your petition.
How To Check If the Fees Are Correct

Form I-539’s filing fee is current as of the edition date in the lower left corner of this page. However, because USCIS fees
change periodically, you can verify that the fees are correct by following one of the steps below.
1. Visit the USCIS website at www.uscis.gov, select “FORMS” and check the appropriate fee; or
2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for the fee information. For TTY (deaf
or hard of hearing) call: 1-800-767-1833.
Fee Waiver

Some forms may be eligible for fee waivers as provided in 8 CFR 106.3. For information on fee waivers, see Form I-912,
Request for Fee Waiver at www.uscis.gov/i-912.

Where to File?
Please see our website at www.uscis.gov/i-539 or call our National Customer Service Center at 1-800-375-5283 for the
most current information about where to file this benefit request. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Penalties
If you knowingly and willfully falsify or conceal a material fact or submit a false document with this request, we will deny
the benefit you are filing for, and may deny any other immigration benefit.
In addition, you will face severe penalties provided by law, and may be subject to criminal prosecution.

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DHS Privacy Notice
AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the
Immigration and Nationality Act sections 1103 and 1184, and Title 8 of the Code of Federal Regulations (CFR) parts 103,
214, and 248.
PURPOSE: The primary purpose for providing the requested information on this form is to apply for an extension of
stay or a change from one nonimmigrant category to another nonimmigrant category. DHS will use the information you
provide to grant or deny the immigration benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information,
including your Social Security number, and any requested evidence, may delay a final decision or result in a rejection or
denial of your form.

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ROUTINE USES: DHS may share the information you provide on this form and any additional requested evidence with
other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine
uses described in the associated published system of records notices [DHS/USCIS-001 - Alien File, Index, and National
File Tracking System and DHS/USCIS-007 - Benefits Information System] and the published privacy impact assessment
[DHS/USCIS/PIA-016(a) Computer Linked Application Information Management System and Associated Systems],
which can be found at www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law enforcement
purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection
of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The
public reporting burden for this collection of information is estimated at 30 minutes per response, including the time for
reviewing instructions, gathering the required documentation and information, completing the application, preparing
statements, attaching necessary documentation, and submitting the application. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S.
Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts
Ave NW, Washington, DC 20529-2140; OMB No. 1615-0003. Do not mail your completed Form I-539A to this
address.

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