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Department of Homeland Security
U.S. Citizenship and Immigration Services
DRAFT
I-539, Application to Extend/
Change Nonimmigrant Status
START HERE - Please type or print in blue or black ink
Part 1.
For USCIS Use Only
Information About You
Family Name (Last Name)
Receipt
Returned
Given Name (First Name)
Middle Name
Date
Address In care of Street Number
and Name
City
Resubmitted
Apt. Number
State
Country of Birth
Date of Birth
Daytime Phone Number
Zip Code
Country of Citizenship
U. S. Social Security # (if any)
A-Number (if any)
(mm/dd/yyyy)
Date of Last Arrival
Into the U.S.
Current Nonimmigrant Status
I-94 Number
Date
Reloc Sent
Date
Reloc Rec'd
Expires on
Date
(mm/dd/yyyy)
Part 2. Application Type (See instructions for fee)
1. I am applying for: (Check one)
a.
An extension of stay in my current status.
b.
A change of status. The new status I am requesting is:
c.
Reinstatement to student status.
Applicant
Interviewed
on
2. Number of people included in this application: (Check one)
a.
I am the only applicant.
Members of my family are filing this application with me.
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. Is this application based on an extension or change of status already granted to your
spouse, child, or parent?
No
Yes. USCIS Receipt #
3. Is this application based on a separate petition or application to give your spouse,
child, or parent an extension or change of status?
No
Yes, filed with this I-539.
Yes, filed previously and pending with USCIS. Receipt #:
4. If you answered "Yes" to Question 3, give the name of the petitioner or applicant:
If the petition or application is pending with USCIS, also give the following data:
Office filed at
Date
Extension Granted to (Date):
Change of Status/Extension Granted
New Class: From (Date):
To (Date):
If Denied:
Still within period of stay
S/D to:
Place under docket control
Remarks:
Action Block
Filed on (mm/dd/yyyy)
Part 4. Additional Information
1. For applicant #1, provide passport information:
Country of Issuance:
2. Foreign Address: Street Number and Name
Valid to: (mm/dd/yyyy)
Apt. Number
City or Town
State or Province
Country
Zip/Postal Code
To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the applicant.
ATTY State License #
Form I-539 (Rev. 08/20/10)Y
DRAFT
3. Answer the following questions. If you answer "Yes" to any question, describe the circumstances in
detail and explain on a separate sheet of paper.
a.
Are you, or any other person included on the application, an applicant for an immigrant visa?
b.
Has an immigrant petition ever been filed for you or for any other person included in this application?
c.
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
d. 1. 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?
d. 2. Have you EVER ordered, incited, called for, commited, assisted, helped with, or otherwise participated in
any of the following:
(a) Acts involving torture or genocide?
(b) Killing any person?
(c) Intentionally and severely injuring any person?
(d) Engaging in any kind of sexual contact or relations with any person who was being forced or
threatened?
(e) Limiting or denying any person's ability to exercise religious beliefs?
d. 3. Have you EVER:
(a) 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?
(b) Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation
that involved detaining persons?
d. 4. Have you 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?
d. 5. Have you EVER assisted or participated in selling or providing weapons to any person who to your
knowledge used them against another person, or in transporting weapons to any person who to your
knowledge used them against another person?
d. 6. Have you EVER received any type of military, paramilitary, or weapons training?
e.
Have you, or any other person included in this application, done anything that violated the terms of the
nonimmigrant status you now hold?
f.
Are you, or any other person included in this application, now in removal proceedings?
g.
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?
1. If you answered "Yes" to Question 3f, give the following information concerning the removal proceedings on the attached
page entitled "Part 4. Additional information. Page for answers to 3f and 3g." Include the name of the person in removal
proceedings and information on jurisdiction, date proceedings began, and status of proceedings.
2. If you answered "No" to Question 3g, fully describe how you are supporting yourself on the attached page entitled "Part 4.
Additional information. Page for answers to 3f and 3g." Include the source, amount, and basis for any income.
3. If you answered "Yes" to Question 3g, fully describe the employment on the attached page entitled "Part 4. Additional
information. Page for answers to 3f and 3g." Include the name of the person employed, name and address of the employer,
weekly income, and whether the employment was specifically authorized by USCIS.
Form I-539 (Rev. 08/20/10)Y Page 2
DRAFT
Yes
h.
No
Are you currently or have you ever been a J-1 exchange visitor or a J-2 dependent of a J-1 exchange visitor?
If "Yes," you must provide the dates you maintained status as a J-1 exchange visitor or J-2 dependent. Willful failure to
disclose this information (or other relevant information) can result in your application being denied. Also, provide proof of
your J-1 or J-2 status, such as a copy of Form DS-2019, Certificate of Eligibility for Exchange Visitor Status, or a copy of
your passport that includes the J visa stamp.
Part 5. Applicant's Statement and Signature (Read the information on penalties in the instructions before completing this
section. You must file this application while in the United States.)
Applicant's Statement (Check One):
Each and every question and instruction on this
form, as well as my answer to each question, has
been read to me by the person named below in
, a language in which
I am fluent. I understand each and every question
and instruction on this form, as well as my
answer to each question.
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
each question.
Applicant's Signature
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit I am seeking.
Signature
Print your Name
Daytime Telephone Number
E-Mail Address
Date
NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible for
the requested benefit and this application may be denied.
Part 6. Interpreter's Statement
Language used:
I certify that I am fluent in English and the above-mentioned language. I further certify that I have read each and every question and
instruction on this form, as well as the answer to each question, to this applicant in the above-mentioned language, and the applicant
has understood each and every instruction and question on the form, as well as the answer to each question.
Signature
Print Your Name
Firm Name
(if applicable)
Daytime Telephone Number
Address
Fax Number (Area Code and Number) E-Mail Address
Date
(Area Code and Number)
Form I-539 (Rev. 08/20/10)Y Page 3
DRAFT
Part 7. Signature of Person Preparing Form, if Other Than Above (Sign Below)
Signature
Print Your Name
Firm Name
(if applicable)
Daytime Telephone Number
Address
Fax Number (Area Code and Number) E-Mail Address
Date
(Area Code and Number)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have
knowledge.
Part 4. (Continued) Additional Information. (Page 2 for answers to 3f and 3g.)
If you answered "Yes" to Question 3f in Part 4 on Page 3 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.
If you answered "No" to Question 3g in Part 4 on Page 3 of this form, fully describe how you are supporting yourself. Include the
source, amount and basis for any income.
If you answered "Yes" to Question 3g in Part 4 on Page 3 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.
Form I-539 (Rev. 08/20/10)Y Page 4
DRAFT
Supplement -1
Attach to Form I-539 when more than one person is included in the petition or application.
(List each person separately. Do not include the person named in Form I-539.)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Country of Birth
Country of Citizenship
U.S. Social Security # (if any)
Date of Birth (mm/dd/yyyy)
A-Number (if any)
Date of Arrival (mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
U.S. Social Security # (if any)
A-Number (if any)
Date of Arrival (mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
U.S. Social Security # (if any)
A-Number (if any)
Date of Arrival (mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
U.S. Social Security # (if any)
A-Number (if any)
Date of Arrival (mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
U.S. Social Security # (if any)
A-Number (if any)
Date of Arrival (mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
If you need additional space, attach a separate sheet of paper.
Place your name, A-Number, if any, date of birth, form number, and application date at the top of the sheet of paper.
Form I-539 (Rev. 08/20/10)Y Page 5
| File Type | application/pdf |
| File Modified | 2010-08-31 |
| File Created | 2007-10-11 |