Page 1, Part 1. Information About You
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Family Name (Last Name)
Given Name (First Name)
Middle Name
Address- In care of
Street Number and Name
Apt. Number
City
State
Zip Code
Daytime Phone Number
[See A-Number below]
Country of Birth
Country of Citizenship
Date of Birth (mm/dd/yyyy)
U.S. Social Security # (if any)
A-Number (if any)
Date of Last Arrival Into the U.S.
(mm/dd/yyyy)
I-94 Number
Current Nonimmigrant Status
Expires on (mm/dd/yyyy)
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1. Alien Registration Number (A-Number)
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 [new
sub-header]
4.a.
In Care Of Name
4.b.
Street Number and Name
4.c.
Apt. Ste. Flr.
4.d.
City or Town
4.e.
State
4.f.
ZIP Code
Physical
Address [new sub-header]
5.a.
Street Number and Name
5.b..
Apt. Ste. Flr.
5.c.
City or Town
5.d.
State
5.e. ZIP Code
[Deleted]
Other
Information [new sub-header]
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)
[See Item
Number 3 above]
10.
Date of Last Arrival Into the U.S. (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).
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Page 1, Part 2. Application Type (See instructions for
fee)
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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.
2. Number of people included
in this application: (Check one)
a. I am the only applicant.
b. Members of my family are
filing this application with me. The total number of people
(including me) in the application is
(Complete the supplement for each co-applicant.)
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[Page 2]
Part 2. Application Type (See
instructions for fee)
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.)
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Page 1, Part 3. Processing Information
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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?
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?
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
Filed on (mm/dd/yyyy)
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[Page 2]
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?
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
Yes, filed previously and pending
with USCIS
No
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
Office where
petition or application filed:
3.d. City
or Town
3.e. State
3.f. Date
Filed (mm/dd/yyyy)
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Pages 1-3, Part 4. Additional Information
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[Page 1]
1. For applicant #1,
provide passport information:
Valid to: (mm/dd/yyyy)
Country of Issuance:
2. Foreign Address:
Street Number and Name
Apt. Number
City or Town
State or Province
Country
Zip/Postal Code
[Page 2]
3. Answer the following
questions. If you answer "Yes" to any question,
describe the circumstances in and explain on a separate sheet of
paper.
a. Are you…
b. Has an …
c. Has Form I-485…
d. 1. Have you…
d. 2. Have you EVER ordered,
incited, called for, committed, assisted, helped with, or
otherwise participated in any of the following:
(a) Acts …
(b) Killing …
(c) Intentionally …
(d) Engaging …
(e) Limiting or …
d. 3. Have you EVER:
(a) Served in…
(b) Served in …
d. 4. Have you EVER …
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 …
e. Have you…
f. Are you…
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.
g. Have you…
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.
[Page 3]
h. Are you currently …
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.
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[Page 2]
Part 4. Additional Information
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…
4.
Has an …
5.
Has Form I-485…
6.
Have you…
Have you , or
any other person included in this application, EVER
ordered, incited, called for, committed, assisted, helped with, or
otherwise participated in any of the following:
7.
Acts …
8.
Killing …
9.
Intentionally …
10.
Engaging in …
11.
Limiting or …
[Page 3]
12.
Have you, or any other person included
in this 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?
13. Have
you, or any other person included in
this application, EVER served
in …
14.
Have you, or any other person included
in this application, EVER …
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?
16.
Have you, or any other person included
in this application, EVER …
17.
Have you…
18.
Are you…
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…
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 …
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.
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Page 3, 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.)
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Applicant's Statement (Check
One):
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.
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 [Language], 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.
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
Date
Daytime Telephone Number
E-Mail Address
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.
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Page 3,
Part 5. Statement,
Certification, Signature, and Contact Information of the Applicant
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 every question and instruction on this form, as
well as my answer to every
question.
1.b.
The interpreter named below
has read to me every question and instruction on this form,
as well as my answer to every
question, in [Language], 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 [Preparer],
who is/is
not an
attorney or accredited
representative, preparing
this form for me.
Applicant Certification
I certify,
under penalty of perjury, that the foregoing
is true and correct. Copies of documents submitted are exact
photocopies of unaltered original documents, and I understand that
I may be required to submit original documents to U.S.
Citizenship and Immigration Services (USCIS) at
a later date. Furthermore, I authorize the release of any
information from 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 of U.S.
immigration laws.
3.a.
Applicant's Signature
3.b.
Date of Signature
(mm/dd/yyyy)
[Page 4]
Applicant's
Contact Information
4.
Applicant’s
Daytime Telephone Number
5.
Applicant’s
Mobile Telephone Number
6.
Applicant’s E-mail Address
[Deleted]
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Page 3, Part 6. Interpreter’ Statement and Signature
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[See below, Print Your Name]
[See below, Firm Name]
[See below, Address]
[See below, Daytime Telephone
Number]
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
Date
Firm Name (if applicable)
Daytime Telephone Number (Area
Code and Number)
Address
Fax Number (Area Code and Number)
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[Page 4]
Part 6. Contact
Information, 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'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
Interpreter
Certification
I certify that:
I am fluent in English and
[Language], 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 to 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.
6.a.
Interpreter's Signature
[See above,
Interpreter's Full Name]
6.b.
Date of Signature
(mm/dd/yyyy)
[See above,
Interpreter's Full Name]
[See above,
Interpreter's Contact Information]
[See above,
Interpreter's Mailing Address]
[Deleted]
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Page 4, Part 7.
Signature of Person Preparing Form, if Other Than Above
(Sign Below)
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[See below, Print Your Name]
[See below, Firm Name]
[See below, Address]
[See below, Daytime Telephone
Number]
[See below, Fax Number]
[See below, E-Mail Address]
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.
Signature
Print Your Name
Date
Firm Name (if applicable)
Daytime Telephone Number (Area
Code and Number)
Address
Fax Number (Area Code and Number)
E-Mail Address
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[Page 4]
Part 7. Contact
Information, Declaration,
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)
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
[Page 5]
Preparer's
Contact Information
4.
Preparer's Daytime
Telephone Number
5.
Preparer's Fax Number
6.
Preparer's E-mail
Address
7.a.
I am not an attorney or
accredited representative but have prepared this fomor 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.
Preparer's
Declaration
By my
signature, I certify, swear or
affirm, under penalty of perjury, that I prepared this form
on behalf of, at the request of, and
with the express consent of, the applicant. I completed the
form based only on responses the
applicant provided to me. After completing the form, I reviewed it
and all of the applicant's responses with the applicant, who
agreed with every answer provided for every
question on the form and, when
required, supplied additional information
to respond to a question on the form.
8.a.
Preparer's Signature
[See above,
Preparer's Full Name]
8.b.
Date of Signature
(mm/dd/yyyy)
[See above,
Interpreter's Full Name]
[See above,
Interpreter's Contact Information]
[See above,
Interpreter's Mailing Address]
[See above,
Interpreter's Contact Information]
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Page 4, Part 4. (Continued) Additional Information.
(Page 2 for answers to 3f and 3g.)
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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.
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[Page 6]
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.
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.
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.
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.
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Page 5, 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.)
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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
[See below, Country Where
Passport Issued and
Expiration Date]
Current Nonimmigrant Status:
Expires on (mm/dd/yyyy)
Country Where Passport Issued
Expiration Date (mm/dd/yyyy)
[Set of same data collections as
above]
[Set of same data collections as
above]
[Set of same data collections as
above]
[Set of same data collections as
above]
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.
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[Page 7]
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)
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)
[See above,
Item Numbers 1.m and 1.n.]
Person Two…
[Set of same
data collections as above, Item Numbers 2.a. to 2.p.]
[Page 8]
Person
Three…
[Set of same
data collections as above, Item Numbers 3.a. to 3.p.]
Person
Four…
[Set of same
data collections as above, Item Numbers 4.a. to 4.p.]
[Page 9]
Person
Five…
[Set of same
data collections as above, Item Numbers 5.a. to 5.p.]
Person Six
[Set of same
data collections as above, Item Numbers 6.a. to 6.p.]
[Deleted]
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