Supplement A To Form I-539 - Uscis (Page 3 of 3) in pdf

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the

Immigration and Nationality Act, section 101, et seq.

PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have

established eligibility for the immigration benefit for which you are filing. The information you provide will be used to

grant or deny the benefit sought.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and

any requested evidence, may delay a final decision or result in denial of your form.

ROUTINE USES: The information you provide on this form may be shared with other Federal, State, local, and foreign

government agencies and authorized organizations following approved routine uses described in the associated published

system of records notices [DHS/USCIS-007 - Benefits Information System and DHS/USCIS-ICE-CBP-001 - Alien File,

Index, and National File Tracking System of Records, which can be found at The information

may also be made available, as appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of

information unless it displays a currently valid OMB control number. The public reporting burden for this collection of

information is estimated at 30 minutes per response, including the time for reviewing instructions and completing and

submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination

Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0004.

Do not mail your completed Form I-539 to this address.

Form I-539 Supplement A Instructions 12/23/16 N

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Supplement A To Form I-539 - Uscis Page 3