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 Accredited
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 12/31/2024

Attorney or Accredited Representative
USCIS Online Account Number (if any)

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► START HERE - Type or print in black ink.

Part 1. Information About the Person Filing Form I-539
1.

Your Full Legal Name

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Part 2. Information About You

Attach to Form I-539 when more than one person is included in the Form I-539 application. Each co-applicant must complete a
separate Form I-539A. Do not submit a Form I-539A for the person named in Form I-539.
1.

Your Full Legal Name

Family Name (Last Name)

Given Name (First Name)

3.

Middle Name (if applicable)

Country of Birth

2.

Date of Birth (mm/dd/yyyy)

4.

Country of Citizenship or Nationality

6.

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

7.

Provide Information About Your Most Recent Entry Into the United States

5.

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

Date of Arrival (mm/dd/yyyy)

Form I-94 Arrival/Departure Record Number
►

Passport Number

Travel Document
Number

Country of Passport or
Travel Document Issuance

Passport or Travel Document Expiration
Date (mm/dd/yyyy)

8.

Current Nonimmigrant Status (for example, F-1 student, H-4 dependent, etc.)

9.

Current Passport Information

Expiration Date (mm/dd/yyyy)

If your current passport information is different from the information you provided in Item Number 8., provide your current
passport information. If your current passport information matches the information you provided in Item Number 8., proceed
to Item Number 10.
Passport Number

10.

Country of Passport Issuance

Passport Expiration Date (mm/dd/yyyy)

USCIS Online Account Number (if any)
►

Form I-539A Edition 05/31/22

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Part 3. Additional Information About You
Answer the following questions. If you answer "Yes" to any of the questions in Item Numbers 1. - 4., use the space provided in Part
7. Additional Information to provide an explanation.
1.

Are you an applicant for an immigrant visa?

Yes

No

2.

Has an immigrant petition EVER been filed for you?

Yes

No

3.

Have you EVER filed a Form I-485, Application to Register Permanent Residence or Adjust Status?

Yes

No

4.

Have you EVER been arrested or convicted of any criminal offense since last entering the United States?

Yes

No

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Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
5.

Acts involving torture or genocide?

Yes

No

6.

Killing any person?

Yes

No

7.

Intentionally and severely injuring any person?

Yes

No

8.

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

9.

Limiting or denying any person's ability to exercise religious beliefs?

Yes

No

Have you EVER:
10.

Served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit,
self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other
armed group?

Yes

No

11.

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

12.

Have you EVER been a member of, assisted, or participated in any group, unit, or organization of any
kind in which you or other persons used or threatened to use any type of weapon against any person or
threatened to do so?

Yes

No

13.

Have you EVER sold, provided, or transported weapons, or assisted any person in selling, providing, or
transporting weapons that you knew or believed would be used against another person?

Yes

No

14.

Have you EVER received any weapons training, paramilitary training, or other military-type training?

Yes

No

15.

Have you EVER violated the terms of the nonimmigrant status you now hold?

Yes

No

16.

Are you now in removal proceedings?

Yes

No

17.

Have you ever 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 17., fully describe how you are supporting yourself in Part 7. Additional Information.
Include documentary evidence of the source, amount, and basis for any income.
If you answered "Yes" to Item Number 17., fully describe any and all periods of employment in Part 7. Additional Information.
18.

Are you 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 18., you must provide the dates you maintained status as a J-1 exchange visitor or J-2
dependent in Part 7. Additional Information.

Form I-539A Edition 05/31/22

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Part 4. Applicant's Contact Information, Certification, and Signature
Applicant's Contact Information
Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

3.

Applicant's Email Address (if any)

2.

Applicant's Mobile Telephone Number (if any)

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Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 5.,
understood, all of the responses and information contained in, and submitted with, my application, and that all of the responses and the
information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
4.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

Part 5. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

I certify, under penalty of perjury, that I am fluent in English and

4.

Interpreter's Mobile Telephone Number (if any)

, and I have interpreted

every question on the application and Instructions and interpreted the applicant's answers to the questions in that language, and the
applicant informed me that they understood every instruction, question, and answer on the application.
6.

Interpreter's Signature

Form I-539A Edition 05/31/22

Date of Signature (mm/dd/yyyy)

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Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

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Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of the responses and information contained in and submitted with the application are complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.

Preparer's Signature

Form I-539A Edition 05/31/22

Date of Signature (mm/dd/yyyy)

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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 form 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
1.

Family Name (Last Name)

Given Name (First Name)

2.

A-Number (if any) ► A-

3.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

Middle Name (if applicable)

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Form I-539A Edition 05/31/22

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