Form I-539 - Application To Extend/change Nonimmigrant Status Page 7
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9Person Two
Supplement A. Attach to Form I-539 when more
2.a.
Family Name
than one person is included in this application.
(Last Name)
(List each person separately. Do not include the
2.b.
Given Name
person named in Form I-539.)
(First Name)
2.c.
Middle Name
Person One
1.a.
Family Name
(mm/dd/yyyy) ►
2.d.
Date of Birth
(Last Name)
1.b. Given Name
2.e. Country of Birth
(First Name)
1.c. Middle Name
2.f.
Country of Citizenship or Nationality
►
1.d.
Date of Birth
(mm/dd/yyyy)
1.e.
Country of Birth
2.g. U.S. Social Security Number (if any)
►
2.h. Alien Registration Number (A-Number)
1.f.
Country of Citizenship or Nationality
►
A-
1.g.
U.S. Social Security Number (if any)
►
2.i.
Date of Arrival
(mm/dd/yyyy)
►
2.j.
I-94 Arrival/Departure Record Number
1.h.
Alien Registration Number (A-Number)
►
►
A-
2.k. Passport Number
(mm/dd/yyyy) ►
1.i.
Date of Arrival
2.l.
Travel Document Number
1.j.
I-94 Arrival/Departure Record Number
►
2.m.
Country of Issuance for Passport or Travel Document
1.k.
Passport Number
1.l.
Travel Document Number
2.n.
Expiration Date for Passport or Travel Document
►
(mm/dd/yyyy)
1.m. Country of Issuance for Passport or Travel Document
2.o. Current Nonimmigrant Status
1.n. Expiration Date for Passport or Travel Document
2.p. Expiration Date (mm/dd/yyyy) ►
(mm/dd/yyyy) ►
1.o.
Current Nonimmigrant Status
►
1.p.
Expiration Date
(mm/dd/yyyy)
Form I-539 12/23/16 N
Page 7 of 9
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