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 11/30/2021

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.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

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

1.c. Middle Name

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

14.

2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

4.

Country of Citizenship or Nationality

13.a. Passport Number

USCIS Online Account Number (if any)
►

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.

5.

6.

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

Applicant's Statement

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

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

► A7.

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 4. read to me every
question and instruction on this form and my answer
to every question in

Date of Arrival (mm/dd/yyyy)

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

1.a.

Form I-94 Arrival-Departure Record Number
►

9.

Passport Number

10.

Travel Document Number

11.a. Country of Passport or Travel Document Issuance

Form I-539A Edition 03/10/21 E

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

At my request, the preparer named in Part 5.,

,
prepared this form for me based only upon
information I provided or authorized.
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Part 3. Applicant's Statement, Contact
Information, Declaration, Certification and
Signature (continued)
Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

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
4.

Applicant's Mobile Telephone Number (if any)

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

5.

Applicant's Email Address (if any)

1.b. Interpreter's Given Name (First 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.

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.

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.

3.c. City or Town

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:

3.f.

3.d. State

Ste.

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

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

Applicant's Signature
6.a. Applicant's Signature

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)

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.

Form I-539A Edition 03/10/21 E

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.
Page 2 of 4

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

Preparer's Statement
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.

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

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

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.

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.

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

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
3.e. ZIP Code

8.a. Preparer's Signature

Province

3.g. Postal Code

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

3.h. Country

Form I-539A Edition 03/10/21 E

Page 3 of 4

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

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

5.d.

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

A-Number (if any)
► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.

4.a. Page Number

6.a. Page Number

6.d.

4.b. Part Number

4.d.

Form I-539A Edition 03/10/21 E

4.c. Item Number

7.a. Page Number

7.d.

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