Pages 1-2,
Part 1. Information
About You
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[Page 1]
Part 1. Information About You
Your Full Name
1.a. Family Name (Last Name)
1.b. Given Name(First Name)
1.c. Middle Name
2. Alien Registration Number
(A-Number) (if any)
3. USCIS Online Account
Number (if any)
U.S. Mailing Address
4.a. In Care Of Name (if
any)
4.b. Street Number and Name
4.c. Apt. Ste. Flr
4.d. City or Town
4.e. State
4.f. Zip Code
U.S. Physical Address
5.a. In Care Of Name (if
any)
5.b. Street Number and Name
5.c. Apt. Ste. Flr
Number
5.d. City or Town
5.e. State
5.f. Zip Code
Other Information About You
6. Country of Birth
7. Country of Citizenship or
Nationality
8. Date of Birth
(mm/dd/yyyy)
9. U.S. Social Security
Number (if any)
10. Date of Last Arrival
Into the United States (mm/dd/yyyy)
Provide Information About Your Most
Recent Entry Into the United States
11. Form I-94
Arrival-Departure Record Number
12. Passport Number
[Page 2]
13. Travel Document Number
14.a. Country of Passport or
Travel Document Issuance
14.b. Passport or Travel
Document Expiration Date (mm/dd/yyyy)
15.a. Current Nonimmigrant
Status (e.g. F-1 student, H-4 dependent, etc.)
15.b. Expiration Date
(mm/dd/yyyy)
16. Select this box if you
were granted Duration of Status (D/S).
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[Page
1]
Part 1. Information About You
1. Your
Full Legal Name
Family Name (Last Name)
Given Name(First Name)
Middle Name
(if applicable)
[no change]
3. USCIS Online Account
Number (if any)
4. Your
U.S. Mailing Address (Safe Address,
if applicable)
In Care
Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City or
Town
State
Zip
Code
5.
Is your mailing address the same
as your physical address? [] Yes [] No
If you
answered “Yes” to Item
Number 5. skip to Item
Number 7. If you answered “No”
to Item Number 5.,
provide information on your physical address in Item
Number 6.
6.
Your
Current Physical
Address
Street
Number
and
Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
[Page 2]
Other
Information About You
7.
Country of Birth
8.
Country of Citizenship or Nationality
9.
Date of Birth (mm/dd/yyyy)
10.
U.S. Social Security Number (if any)
[Incorporated
into Item Number 10.]
11.
Provide Information About Your Most Recent Entry Into the
United States
Date of Last
Arrival Into the United States (mm/dd/yyyy)
Form
I-94 Arrival-Departure Record Number
Passport
Number (if any)
Travel
Document Number (if any)
Country
of Passport or Travel Document Issuance
Passport or
Travel Document Expiration Date (mm/dd/yyyy)
12.
Current Nonimmigrant Status (for
example, F-1 student, H-4 dependent, etc.)
Date Status
Expires (mm/dd/yyyy)
Select
this box if you were granted Duration of Status (D/S).
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Page 2,
Part 3. Processing
Information
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[Page 2]
Part 3. Processing Information
1. I/We request that my/our
current or requested status be extended until (mm/dd/yyyy):
[fillable field]
2.a. Is this application
based on an extension or change of status already granted to your
spouse, child, or parent?
Yes
No
2.b. If you answered "Yes"
to Item Number 2.a., provide USCIS Receipt Number.
3.a Is this application
based on a separate petition or application to provide your
spouse, child, or parent an extension or change of status?
[] Yes, filed with this Form I-539.
[] No
[] Yes, filed previously and pending
with U.S. Citizenship and Immigration Services (USCIS).
3.b. If pending with USCIS,
provide USCIS Receipt Number.
[new]
[moved down]
If the petition or application is
pending with USCIS, also provide the following information:
4. First and Last Name of
Petitioner or Applicant
5. Date Filed (mm/dd/yyyy)
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[Page 2]
Part 3. Processing Information
1. I/We request that my/our
current or requested status be extended until (mm/dd/yyyy):
[fillable field]
2.
Is this application based on an extension or change of status
already granted to your spouse, child, or parent?
[] Yes
[] No
[moved down]
[Page 3]
3.
Is this application based on a separate petition or application to
provide your spouse, child, or parent an extension or change of
status?
[] Yes, filed with this Form I-539.
[] No.
[] Yes, filed previously and pending
with U.S. Citizenship and Immigration Services (USCIS).
[] Yes, filed
previously and already approved by USCIS.
4. If
you answered “Yes” to Item
Number 2. or
Item Number 3., select the Form
type below.
[] Form I-539,
Application to Extend/Change Nonimmigrant Status
[] Form I-129,
Petition for a Nonimmigrant Worker
5. If
you answered “Yes” to Item
Number 2. or 3.,
provide the USCIS Receipt Number.
If the petition or application is
pending with USCIS, also provide the following information:
6.
First and Last Name of Beneficiary
or Applicant
First Name of Beneficiary
or Applicant
Last Name of Beneficiary
or Applicant
7.
Date Filed (mm/dd/yyyy)
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Pages 2-3,
Part 4. Additional
Information About the Principal Applicant
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[Page 2]
Part 4. Additional Information
About the Principal Applicant
Provide Your Current Passport
Information (if different from Part 1.)
1.a. Passport Number
1.b. Country of Passport
Issuance
1.c. Passport Expiration
Date (mm/dd/yyyy)
Physical Address Abroad
2.a. Street Number and Name
2.b. Apt. Ste. Flr.
2.c. City or Town
2.d. Province
2.e. Postal Code
2.f. Country
Answer the following questions. If
you answer “Yes” to any of the questions in Item
Numbers 3. - 15., use the space provided in Part 8.
Additional Information to provide an explanation.
[Page 3]
3. Are you, or any other
person included on the application, an applicant for an immigrant
visa?
Yes
No
4. Has an immigrant
petition EVER been filed for you or for any other person
included in this application?
Yes
No
5. Has Form I-485,
Application to Register Permanent Residence or Adjust Status, EVER
been filed by you or by any other person included in this
application?
Yes
No
6. Have you, or any other
person included in this application, EVER been arrested or
convicted of any criminal offense since last entering the United
States?
Yes
No
Have you, or any other person
included on the application, EVER ordered, incited, called
for, committed, assisted, helped with, or otherwise participated
in any of the following:
7.a. Acts involving torture
or genocide?
Yes
No
7.b. Killing any person?
Yes
No
7.c. Intentionally and
severely injuring any person?
Yes
No
7.d. 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
7.e. Limiting or denying any
person's ability to exercise religious beliefs?
Yes
No
Have you, or any other person
included on the application, EVER:
8.a. 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
8.b. 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
9. Have you, or any other
person included in this application, EVER been a member of,
assisted, or participated in any group, unit, or organization of
any kind in which you or other persons used any type of weapon
against any person or threatened to do so?
Yes
No
10. Have you, or any other
person included in this application, EVER assisted or
participated in selling, providing, or transporting weapons to any
person who, to your knowledge, used them against another person?
Yes
No
11. Have you, or any other
person included in this application, EVER received any type
of military, paramilitary, or weapons training?
Yes
No
12. Have you, or any other
person included in this application, done anything that violated
the terms of the nonimmigrant status you now hold?
Yes
No
13. Are you, or any other
person included in this application, now in removal proceedings?
Yes
No
If you answered “Yes” to
Item Number 13., provide the following information
concerning the removal proceedings in the space provided in Part
8. Additional Information. Include the name of the person in
removal proceedings and information on jurisdiction, date
proceedings began, and status of proceedings.
14. Have you, or any other
person included in this application, 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 14., fully describe how you are supporting
yourself in Part 8. Additional Information. Include
documentary evidence of the source, amount, and basis for any
income.
If you answered “Yes”
to Item Number 14., fully describe the employment in Part
8. Additional Information. Include the name of the person
employed, name and address of the employer, weekly income, and
whether the employment was specifically authorized by USCIS.
15. Are you, or any other
person included in this application, 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 15., you must provide the dates you maintained
status as a J-1 exchange visitor or J-2 dependent in Part 8.
Additional Information.
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[Page 3]
Part 4. Additional Information
About the Principal Applicant
1.
Current Passport Information
If your
current passport information is different from the information you
provided in Part 1.,
provide your current passport information. If your current
passport information matches the information you provided in Part
1., proceed to Item
Number 3.
Passport
Number
Country
of Passport Issuance
Passport
Expiration Date (mm/dd/yyyy)
2.
Physical Address Abroad
Street
Number and Name
Apt.
Ste. Flr. Number
City or
Town
Province
Postal
Code
Country
[Page 3]
Answer the following questions. If
you answer “Yes” to any of the questions in Item
Numbers 3. - 15., use the
space provided in Part 8. Additional Information to provide
an explanation.
3. Are you
an applicant for an immigrant visa?
Yes
No
4. Has an immigrant
petition EVER been filed for you?
Yes
No
5. Have
you EVER
filed Form I-485, Application to Register Permanent
Residence or Adjust Status?
Yes
No
[Page 4]
6. Have you
been arrested or convicted of any criminal offense since
last entering the United States?
Yes
No
Have you EVER
ordered, incited, called for, committed, assisted, helped with, or
otherwise participated in any of the following:
7.a. Acts involving torture
or genocide?
Yes
No
7.b. Killing any person?
Yes
No
7.c. Intentionally and
severely injuring any person?
Yes
No
7.d. 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
7.e. Limiting or denying
any person's ability to exercise religious beliefs?
Yes
No
Have you EVER:
8.a. 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
8.b. 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
9. 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
10. Have you
EVER
sold, provided, or transported weapons, or assisted any person in
selling, providing, or transporting weapons, which, you knew or
believed would be used against another person?
Yes
No
11. Have you
EVER received any
weapons training, paramilitary training, or
other military-type training?
Yes
No
12. Have you EVER
violated the terms of the nonimmigrant status you now hold?
Yes
No
13. Are you
now in removal proceedings?
Yes
No
[deleted]
14. 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 14., fully
describe how you are supporting yourself in Part 8. Additional
Information. Include documentary evidence of the source,
amount, and basis for any income.
If you answered “Yes” to
Item Number 14., fully describe
any and all periods of employment in
Part 8. Additional Information. Include the
name and address of the employer, weekly income, and
whether the employment was specifically authorized by USCIS.
15. 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 15., you must provide the dates you maintained
status as a J-1 exchange visitor or J-2 dependent in Part 8.
Additional Information.
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Page 4,
Part 5. Applicant's
Statement, Contact Information, Declaration, Certification and
Signature
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[Page 4]
Part 5. Applicant's Statement,
Contact Information, Declaration, Certification and Signature
NOTE: Read the Penalties
section of the Form I-539 Instructions before completing this
section.
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 application and my answer to every
question.
1.b. The interpreter named
in Part 6. read to me every question and instruction
on this application and my answer to every question in [Fillable
Field], a language in which I am fluent, and I understood
everything.
2. At my request, the
preparer named in Part 7. [Fillable field], prepared this
application for me based only upon information I provided or
authorized.
Applicant’s Contact
Information
[new]
3. Applicant’s Daytime
Telephone Number
4. Applicant’s Mobile
Telephone Number (if any)
5. Applicant’s Email
Address (if any)
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 application, 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
application; 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 application 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 application and that all of this information is
complete, true, and correct.
Applicant’s Signature
6.a. Applicant's Signature
6.b. Date of Signature
(mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If
you do not completely fill out this application or fail to submit
required documents listed in the Instructions, USCIS may deny your
application.
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[Page 5]
Part 5. Applicant’s
Contact Information, Certification, and Signature
[deleted]
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
2.
Applicant’s
Mobile Telephone Number
(if any)
3.
Applicant’s
Email Address (if any)
[deleted]
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
6.,
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)
[deleted]
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Pages 4-5,
Part 6.
Interpreter’s Contact Information, Statement, Certification,
and Signature
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[Page 4]
Part 6. Interpreter’s
Contact Information, Statement, Certification, and Signature
Provide the following information
about the interpreter.
Interpreter's Full Name
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)
[Page 5]
Interpreter's Mailing Address
3.a . Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
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)
Interpreter’s
Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [Fillable
Field], which is the same language specified in Part 5.,
Item Number 1.b., and I have read to this applicant in the
identified language every question and instruction on this
application and his or her answer to every question. The
applicant informed me that he or she understands every
instruction, question, and answer on the application, including
the Applicant’s Declaration and Certification, and
has verified the accuracy of every answer.
Interpreter’s Signature
7.a. Interpreter's Signature
7.b. Date of Signature
(mm/dd/yyyy)
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[Page 5]
Part
6. Interpreter’s Contact Information,
Certification, and Signature
[deleted]
Interpreter’s
Full Name
1.
Interpreter’s
Family Name (Last Name)
Interpreter’s
Given Name (First Name)
2.
Interpreter’s
Business or Organization Name
[deleted]
Interpreter’s
Contact
Information
3.
Interpreter’s
Daytime Telephone Number
4.
Interpreter’s
Mobile Telephone Number (if any)
5.
Interpreter’s
Email Address (if any)
Interpreter’s
Certification and
Signature
I
certify, under penalty of perjury, that
I
am fluent in
English and [Fillable language field],
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.
[deleted]
6.
Interpreter’s
Signature
Date of Signature (mm/dd/yyyy)
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Pages 5-6,
Part 7. Contact
Information, Declaration, and Signature of the Person Preparing
this Application, if Other Than the Applicant
|
[Page 5]
Part 7. Contact Information,
Declaration, and Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information
about the preparer.
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
Preparer's Mailing Address
3.a. Street Number and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
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)
[Page 6]
Preparer’s Statement
7.a. I am not an attorney or
accredited representative but have prepared this application 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 application.
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 application.
Preparer's Certification
By my signature, I certify, under
penalty of perjury, that I prepared this application at the
request of the applicant. The applicant then reviewed this
completed application and informed me that he or she understands
all of the information contained in, and submitted with, his or
her application, including the Applicant’s Declaration
and Certification, and that all of this information is
complete, true, and correct. I completed this application based
only on information that the applicant provided to me or
authorized me to obtain or use.
Preparer’s Signature
8.a. Preparer's Signature
8.b. Date of Signature
(mm/dd/yyyy)
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[Page 6]
Part 7. Contact Information,
Declaration, and Signature of the Person Preparing this
Application, if Other Than the Applicant
[deleted]
Preparer’s
Full Name
1.
Preparer’s
Family Name (Last Name)
Preparer’s
Given Name
(First Name)
2.
Preparer’s Business or Organization Name
[deleted]
Preparer’s
Contact
Information
3.
Preparer’s
Daytime Telephone Number
4.
Preparer’s
Mobile Telephone Number (if any)
5.
Preparer’s
Email Address (if any)
[deleted]
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.
[deleted]
6.
Preparer’s
Signature
Date of
Signature (mm/dd/yyyy)
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