Form I-539 - Application To Extend/change Nonimmigrant Status Page 2
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9Part 2. Application Type (See instructions for fee)
Part 4. Additional Information
I am applying for: (Select one)
If you are the Principal Applicant, provide your current Passport
information:
1.
An extension of stay in my current status.
1.a.
Country of Issuance for Passport
2.a.
A change of status. The new status and effective date
►
of change.
(mm/dd/yyyy)
1.b. Expiration Date for Passport
2.b.
The change of status I am requesting is:
(mm/dd/yyyy) ►
Foreign Home Address
3.
Reinstatement to student status.
2.a.
Street Number
Number of people included in this application: (Select one)
and Name
4.
I am the only applicant.
2.b. Apt.
Ste.
Flr.
5.a.
Members of my family are filing this application with
me.
2.c. City or Town
5.b.
The total number of people (including me) in the
2.d. Province
application is: (Complete the supplement for each
co-applicant.)
2.e. Postal Code
Part 3. Processing Information
2.f.
Country
1.a.
I/We request that my/our current or requested status be
Answer the following questions. If you answer "Yes" to any
(mm/dd/yyyy) ►
question, describe the circumstances in detail and explain on a
extended until
separate sheet of paper.
1.b.
Check this box if you were granted, or are seeking,
3.
Are you, or any other person included on the application,
Duration of Status (D/S).
an applicant for an immigrant visa?
Yes
No
2.a. Is this application based on an extension or change of
status already granted to your spouse, child, or parent?
4.
Has an immigrant petition EVER been filed for you or for
any other person included in this application?
Yes
No
Yes
No
2.b. If "Yes," provide USCIS Receipt Number.
5.
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?
3.a. Is this application based on a separate petition or application
Yes
No
to give your spouse, child, or parent an extension or change
of status?
6.
Have you, or any other person included in this application,
Yes, filed with this I-539.
No
EVER been arrested or convicted of any criminal offense
since last entering the United States?
Yes, filed previously and pending with USCIS.
Yes
No
3.b.
If pending with USCIS, provide USCIS Receipt Number
Have you, or any other person included on the application,
►
EVER ordered, incited, called for, committed, assisted, helped
with, or otherwise participated in any of the following:
If the petition or application is pending with USCIS, also give
7.
Acts involving torture or genocide?
Yes
No
the following data:
8.
Killing any person?
Yes
No
3.c. First and last name of petitioner or applicant
9.
Intentionally and severely injuring any person?
Yes
No
Office where petition or application filed:
10.
Engaging in any kind of sexual contact or relations with
3.d. City or Town
any person who was being forced or threatened?
3.e. State
Yes
No
11.
Limiting or denying any person's ability to exercise
►
3.f.
Date Filed
(mm/dd/yyyy)
religious beliefs?
Yes
No
Form I-539 12/23/16 N
Page 2 of 9
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