Form I539 – Fill Out and Use This PDF

For USCIS Use Only									Fee Stamp
Returned
Resubmitted
Relocated	Received
	Sent
Remarks:		Granted							Denied
		New Class							Still within period of stay
			From			/	/	/	S/D to:
		Dates:
			To			/	/	/	Place under docket control

Action Block

Applicant interviewed on

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)

► A-

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. Street Number

and Name

5.b. Apt. Ste. Flr.

5.c. City or Town

5.d. State		5.e. 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

Part 1. Information about You (continued)

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).

Part 2. Application Type

I am applying for (select only one box):

1.	Reinstatement to student status.
2.	An extension of stay in my current status.
3.a.	A change of status.

3.b. New status and effective date of change (mm/dd/yyyy)

3.c. The change of status I am requesting is:

Number of people included in this application (select only one box):

4.	I am the only applicant.

5.a. Members of my family are filing this application with me.

5.b. The total number of people (including me) in the application is: (Complete the supplement for each co- applicant.)

Part 3. Processing Information

1.I/We request that my/our current or requested status be

extended until (mm/dd/yyyy):

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.

►

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)

Part 4. Additional Information About the 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.

Part 4. Additional Information About the Applicant (continued)

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, guerrilla 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.

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
		,
	a language in which I am fluent, and I understood
	everything.
2.	At my request, the preparer named in Part 7.,
		,

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

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.

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)

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.

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)

Part 6. Interpreter's Contact Information, Statement, Certification, and Signature

(continued)

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

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

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:

3.d. State

3.f. Province

3.g. Postal Code 3.h. Country

3.e. ZIP Code

I am fluent in English and		,

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)

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.

7.b.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent.

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.

Part 8. Additional Information

If you need extra space to provide any additional information within this application, 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)

► A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

3.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.