Form I-539 - Application To Extend/change Nonimmigrant Status
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9USCIS
Application to Extend/Change Nonimmigrant Status
Form I-539
Department of Homeland Security
OMB No. 1615-0003
U.S. Citizenship and Immigration Services
Expires 04/30/2018
Action Block
Fee Stamp
For USCIS Use Only
Returned
Resubmitted
Received
Relocated
Sent
Remarks:
Granted
Denied
New Class
Still within period of stay
From
/
/
/
S/D to:
Dates:
Applicant interviewed on
To
/
/
/
Place under docket control
Select this box if G-28 is attached to represent the applicant.
To Be Completed by an Attorney
or Accredited Representative, if any.
Attorney State License Number:
Part 1. Information About You
Other Information
1.
Alien Registration Number (A-Number)
6.
Country of Birth
►
A-
2.
USCIS Online Account Number (if any)
7.
Country of Citizenship or Nationality
►
3.a. Family Name
►
8.
Date of Birth
(mm/dd/yyyy)
(Last Name)
3.b. Given Name
9.
U.S. Social Security Number (if any)
(First Name)
►
3.c. Middle Name
10.
Date of Last Arrival Into the United States
(mm/dd/yyyy) ►
Mailing Address
4.a. In Care Of Name
Provide information about your most recent Form I-94
11.a.
I-94 Arrival-Departure Record Number
►
4.b.
Street Number
and Name
11.b.
Passport Number
4.c. Apt.
Ste.
Flr.
11.c.
Travel Document Number
4.d.
City or Town
11.d. Country of Issuance for Passport or Travel Document
4.e. State
4.f.
ZIP Code
11.e. Expiration Date for Passport or Travel Document
Physical Address
(mm/dd/yyyy) ►
5.a. Street Number
and Name
12.a.
Current Nonimmigrant Status
5.b.
Apt.
Ste.
Flr.
5.c.
City or Town
►
12.b.
Expiration Date
(mm/dd/yyyy)
5.d.
State
5.e.
ZIP Code
12.c.
Check this box if you were granted Duration of Status
(D/S).
Form I-539 12/23/16 N
Page 1 of 9
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