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 (if any).

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

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

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.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

5.

U.S. Social Security Number (if any)
►

6.

Part 3. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature

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

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

7.

USCIS Online Account Number (if any)
►

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
►

9.

Passport Number

10.

Travel Document Number

Form I-539A Edition 10/15/19

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.

Page 1 of 5

Applicant's Signature

Part 3. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
1.b.

6.a. Applicant's Signature

The interpreter named in Part 5. read to me every
question and instruction on this form and my answer
to every question in

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

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

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.

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

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,

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

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Part 4. Interpreter's Contact Information,
Statement, Certification, and 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.

Interpreter's Full Name

Applicant's Declaration and 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
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.
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 form; and

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

(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

3.g. Postal Code
3.h. Country

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 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.

Form I-539A Edition 10/15/19

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Preparer's Mailing Address

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

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

Apt.

Ste.

Flr.

Interpreter's Contact Information
4.

3.c. City or Town

Interpreter's Daytime Telephone Number

3.d. State
5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

3.f.

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 3., 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.

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Signature

Preparer's Statement

7.a. Interpreter's Signature

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. Date of Signature (mm/dd/yyyy)

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.

Part 5. 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.

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 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-539A Edition 10/15/19

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Part 5. 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 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.

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

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

Form I-539A Edition 10/15/19

Page 4 of 5

5.a. Page Number

Part 6. 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)

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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-539A Edition 10/15/19

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