Uscis I 539 Form – 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

To Be Completed by an Attorney or Accredited Representative, if any.

Select this box if G-28 is attached to represent the applicant. Attorney State License Number:

Part 1. Information About You

1.Alien Registration Number (A-Number)

► A-

2.USCIS ELIS Account Number (if any)

►

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

Mailing Address

4.a. In Care Of Name

4.b.	Street Number
	and Name
	Apt.
4.c.			Ste.		Flr.
4.d.	City or Town
4.e.	State				4.f. ZIP Code

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

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 Form I-94

11.a. I-94 Arrival-Departure Record Number

►

11.b. Passport Number

11.c. Travel Document Number

11.d. Country of Issuance for Passport or Travel Document

11.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy) ►

12.a. Current Nonimmigrant Status

12.b. Expiration Date (mm/dd/yyyy) ►

12.c. Check this box if you were granted Duration of Status (D/S).

Part 2. Application Type (See instructions for fee)

Part 4. Additional Information

I am applying for: (Select one)

1.	An extension of stay in my current status.
2.a.	A change of status. The new status and effective date
	of change. (mm/dd/yyyy) ►
2.b. The change of status I am requesting is:
3.	Reinstatement to student status.

Number of people included in this application: (Select one)

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.a. I/We request that my/our current or requested status be extended until (mm/dd/yyyy) ►

1.b.	Check this box if you were granted, or are seeking,
	Duration of Status (D/S).

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 "Yes," provide USCIS Receipt Number.

►

3.a.

Is this application based on a separate petition or application

to give your spouse, child, or parent an extension or change

of status?

Yes, filed with this I-539.

No

Yes, filed previously and pending with USCIS.

3.b. If pending with USCIS, provide USCIS Receipt Number

►

If the petition or application is pending with USCIS, also give the following data:

3.c. First and last name of petitioner or applicant

If you are the Principal Applicant, provide your current Passport information:

1.a. Country of Issuance for Passport

1.b. Expiration Date for Passport

(mm/dd/yyyy) ►

Foreign Home Address

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 question, describe the circumstances in detail and explain on a separate sheet of paper.

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.	Acts involving torture or genocide?	Yes	No
8.	Killing any person?	Yes	No

9.Intentionally and severely injuring any person?

Office where petition or application filed:

3.d. City or Town

3.e. State

3.f. Date Filed

(mm/dd/yyyy) ►

Yes

No

10.Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?

Yes

No

11.Limiting or denying any person's ability to exercise

religious beliefs?

Yes

No

Part 4. Additional Information (continued)

12. Have you, or any other person included on the application, EVER served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla

group, militia, or insurgent organization?

Yes No

13.Have you, or any other person included in this application, EVER served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved

detaining persons?	Yes	No

14.Have you, or any other person included in this application, EVER been a member of, assisted in, 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

15.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

16.Have you, or any other person included in this application, EVER received any type of military, paramilitary, or

weapons training?	Yes	No

17.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

18.Are you, or any other person included in this application,

now in removal proceedings?	Yes	No

If "Yes," provide the following information concerning the removal proceedings in Part 4. Additional Information for Answers to Item Numbers 18., 19., and 20. Include the name of the person in removal proceedings and information on jurisdiction, date proceedings began, and status of proceedings.

19.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 "No," fully describe how you are supporting yourself in

Part 4. Additional Information for Answers to Item

Numbers 18., 19., and 20. Include documentary evidence of the source, amount, and basis for any income.

If "Yes," fully describe the employment in Part 4. Additional

Information for Answers to Item Numbers 18., 19., and 20.

Include the name of the person employed, name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS.

20.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 "Yes," you must provide the dates you maintained status as a J-1 exchange visitor or J-2 dependent in Part 4. Additional

Information for Answers to Item Numbers 18., 19. and 20.

Part 5. Applicant's Statement, Contact Information, Certification and Signature

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 have read and
	understand each and every question and instruction
	on this form, as well as my answer to every question.
1.b.	The interpreter named in Part 6. has also read to me
	every question and instruction on this form, as well
	as my answer to every question, in

,

a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above.

2.	I have requested the services of and consented to

,

who is

is not

an attorney or accredited

representative, preparing this form for me.

Applicant's Certification

I certify, under penalty of perjury, that the information in my form and any document submitted with my form is true and correct. 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 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 laws.

3.a. Applicant's Signature

3.b. Date of Signature (mm/dd/yyyy) ►

Part 5. Applicant's Statement, Contact Information, Certification and Signature (continued)

Applicant's Contact Information

4.Applicant's Daytime Telephone Number

5.Applicant's Mobile Telephone Number

6.Applicant's E-mail Address

Part 6. Contact Information, Statement, Certification, and Signature of the Interpreter

Interpreter's Full Name

Provide the following information concerning the interpreter: 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 Certification

I certify that:
I am fluent in English and	, which

is the same language provided in Part 5., Item Number 1.b.;

I have read to this applicant every question and instruction on this form, as well as the answer every question, in the language provided in Part 5., Item Number 1.b.; and

The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question, and the applicant verified the accuracy of every answer..

6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy) ►

Part 7. Contact Information, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant

Preparer's Full Name

Provide the following information concerning the preparer: 1.a. Preparer's Family Name (Last Name)

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

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 E-mail Address

2.Preparer's Business or Organization Name

Preparer's Mailing Address

3.a.	Street Number
	and Name
	Apt.
3.b.			Ste.				Flr.
3.c.	City or Town
3.d.	State				3.e. ZIP Code
3.f.	Province
3.g.	Postal Code
3.h.	Country

7.a.

7.b.

I am not an attorney or accredited representative but have prepared this form 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 (choose one) extends does not extend beyond the preparation of this form.

Part 4. (continued) Additional Information for

Answers to Item Numbers 18., 19., and 20.

If you answered "Yes" to Item Number 18. in Part 4. of this

form, give the following information concerning the removal proceedings. Include the name of the person in removal proceedings and information on jurisdiction, date proceedings began, and status of proceedings.

1.

If you answered "No" to Item Number 19. in Part 4. of this

form, fully describe how you are supporting yourself. Include the source, amount, and basis for any income.

2.

If you answered "Yes" to Item Number 19. in Part 4. of this form, fully describe the employment. Include the name of the person employed, name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS.

3.

If you answered "Yes" to Item Number 20. in Part 4. of this form, list the name and dates of the person or persons who maintained status as a J-1 exchange visitor or J-2 dependent.

4.

Supplement A. Attach to Form I-539 when more than one person is included in this application.

(List each person separately. Do not include the person named in Form I-539.)

Person One

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

1.d.

Date of Birth

(mm/dd/yyyy)

►

1.e.

Country of Birth

1.f.

Country of Citizenship or Nationality

1.g.

U.S. Social Security Number (if any)

►

1.h.

Alien Registration Number (A-Number)

► A-

1.i.

Date of Arrival

(mm/dd/yyyy)

►

1.j.

I-94 Arrival/Departure Record Number

►

1.k.

Passport Number

1.l.

Travel Document Number

1.m.

Country of Issuance for Passport or Travel Document

1.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

1.o.

Current Nonimmigrant Status

1.p.

Expiration Date (mm/dd/yyyy)

►

Person Two

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

2.d.

Date of Birth

(mm/dd/yyyy)

►

2.e.

Country of Birth

2.f.

Country of Citizenship or Nationality

2.g. U.S. Social Security Number (if any)

►

2.h.

Alien Registration Number (A-Number)

► A-

2.i.

Date of Arrival

(mm/dd/yyyy)

►

2.j.

I-94 Arrival/Departure Record Number

►

2.k.

Passport Number

2.l.

Travel Document Number

2.m.

Country of Issuance for Passport or Travel Document

2.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

2.o.

Current Nonimmigrant Status

2.p.

Expiration Date (mm/dd/yyyy)

►

Supplement A. Attach to Form I-539 when more than one person is included in this application.

(List each person separately. Do not include the person named in Form I-539.) (continued)

Person Three

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

3.d.

Date of Birth

(mm/dd/yyyy)

►

3.e.

Country of Birth

3.f.

Country of Citizenship or Nationality

3.g.

U.S. Social Security Number (if any)

►

3.h.

Alien Registration Number (A-Number)

► A-

3.i.

Date of Arrival

(mm/dd/yyyy)

►

3.j.

I-94 Arrival/Departure Record Number

►

3.k.

Passport Number

3.l.

Travel Document Number

3.m.

Country of Issuance for Passport or Travel Document

3.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

3.o.

Current Nonimmigrant Status

3.p.

Expiration Date (mm/dd/yyyy)

►

Person Four

4.a. Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

4.d.

Date of Birth

(mm/dd/yyyy)

►

4.e.

Country of Birth

4.f.

Country of Citizenship or Nationality

4.g. U.S. Social Security Number (if any)

►

4.h.

Alien Registration Number (A-Number)

► A-

4.i.

Date of Arrival

(mm/dd/yyyy)

►

4.j.

I-94 Arrival/Departure Record Number

►

4.k.

Passport Number

4.l.

Travel Document Number

4.m.

Country of Issuance for Passport or Travel Document

4.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

4.o.

Current Nonimmigrant Status

4.p.

Expiration Date (mm/dd/yyyy)

►

Supplement A. Attach to Form I-539 when more than one person is included in this application.

(List each person separately. Do not include the person named in Form I-539.) (continued)

Person Five

5.a. Family Name

(Last Name)

5.b. Given Name

(First Name)

5.c. Middle Name

5.d.

Date of Birth

(mm/dd/yyyy)

►

5.e.

Country of Birth

5.f.

Country of Citizenship or Nationality

5.g.

U.S. Social Security Number (if any)

►

5.h.

Alien Registration Number (A-Number)

► A-

5.i.

Date of Arrival

(mm/dd/yyyy)

►

5.j.

I-94 Arrival/Departure Record Number

►

5.k.

Passport Number

5.l.

Travel Document Number

5.m.

Country of Issuance for Passport or Travel Document

5.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

5.o.

Current Nonimmigrant Status

5.p.

Expiration Date (mm/dd/yyyy)

►

Person Six

6.a. Family Name

(Last Name)

6.b. Given Name

(First Name)

6.c. Middle Name

6.d.

Date of Birth (mm/dd/yyyy)

►

6.e.

Country of Birth

6.f.

Country of Citizenship or Nationality

6.g.

U.S. Social Security Number (if any)

►

6.h.

Alien Registration Number (A-Number)

► A-

6.i.

Date of Arrival (mm/dd/yyyy)

►

6.j.

I-94 Arrival/Departure Record Number

►

6.k.

Passport Number

6.l.

Travel Document Number

6.m.

Country of Issuance for Passport or Travel Document

6.n.

Expiration Date for Passport or Travel Document

(mm/dd/yyyy)

►

6.o.

Current Nonimmigrant Status

6.p.

Expiration Date (mm/dd/yyyy)

►