Page 1,
Part 2. Information
About You
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[Page 1]
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)
1.c. Middle Name
2. Date of Birth
(mm/dd/yyyy)
3. Country of Birth
4. Country of Citizenship or
Nationality
5. U.S. Social Security
Number (if any)
6. Alien Registration Number
(A-Number) (if any)
7. 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
11.a. Country of Passport or
Travel Document Issuance
11.b. Passport or Travel
Document Expiration Date (mm/dd/yyyy)
12.a. Current Nonimmigrant
Status
12.b. Expiration Date
(mm/dd/yyyy)
Provide Your Current Passport
Information (if different from Item Number 9.)
[new]
13.a. Passport Number
13.b. Country of Passport
Issuance
13.c. Passport Expiration
Date (mm/dd/yyyy)
14. USCIS Online Account
Number (if any)
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[Page 1]
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)
Middle Name (if
applicable)
[no change]
[renumbered
and moved down]
7. Provide
Information About Your Most Recent Entry Into the United States
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.)
Expiration
Date (mm/dd/yyyy)
9.
Current Passport Information
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
Country of
Passport Issuance
Passport
Expiration Date (mm/dd/yyyy)
10. USCIS
Online Account Number (if any)
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New
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[new]
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[Page 2]
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
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.
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Pages 1-2,
Part 3. Applicant's
Statement, Contact Information, Declaration, Certification and
Signature
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[Page 1]
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.
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.
1.b. The interpreter named
in Part 5. read to me every question and instruction on
this form 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 6., [Fillable field], prepared this
form for me based only upon information I provided or authorized.
[Page 2]
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 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
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
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.
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[Page 3]
Part
4. 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)
Applicant’s
Certification
and Signature
[deleted]
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.
[deleted]
4.
Applicant’s
Signature
Date
of
Signature (mm/dd/yyyy)
[deleted]
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Pages 2-3,
Part 4.
Interpreter’s Contact Information, Statement, Certification,
and Signature
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[Page 2]
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
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
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 4., 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 3]
Interpreter’s Signature
7.a Interpreter's Signature
7.b. Date of Signature
(mm/dd/yyyy)
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[Page 4]
Part 5.
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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Page 3,
Part 5. Contact
Information, Declaration, and Signature of the Person Preparing
this Application, if Other Than the Applicant
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[Page 3]
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)
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)
Preparer’s Statement
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
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
8.a. Preparer's Signature
8.b. Date of Signature
(mm/dd/yyyy)
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[Page 5]
Part 6.
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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Page 4,
Part 6. Additional
Information
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[Page 4]
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.
1.a. Family Name (Last Name)
1.b. Given Name (First Name)
1.c. Middle Name
2. A-Number (if any)
3.a. Page Number
3.b. Part Number
3.c. Item Number
3.d. [Fillable field]
4.a. Page Number
4.b. Part Number
4.c. Item Number
4.d. [Fillable field]
5.a. Page Number
5.b. Part Number
5.c. Item Number
5.d. [Fillable field]
6.a. Page Number
6.b. Part Number
6.c. Item Number
6.d. [Fillable field]
7.a. Page Number
7.b. Part Number
7.c. Item Number
7.d. [Fillable field]
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[Page 6]
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)
Middle Name (if applicable)
2. A-Number (if any)
3.
Page Number
Part Number
Item Number
[Fillable
field]
4.
Page Number
Part Number
Item Number
[Fillable
field]
5.
Page Number
Part Number
Item Number
[Fillable
field]
6.
Page Number
Part Number
Item Number
[Fillable
field]
[delete]
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