Form I-539 - Application To Extend/change Nonimmigrant Status Page 3
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920.
Are you, or any other person included in this application,
Part 4. Additional Information (continued)
currently or have you ever been a J-1 exchange visitor or
12.
Have you, or any other person included on the application,
a J-2 dependent of a J-1 exchange visitor?
EVER served in, been a member of, assisted in, or
Yes
No
participated in any military unit, paramilitary unit, police
unit, self-defense unit, vigilante unit, rebel group, guerrilla
If "Yes," you must provide the dates you maintained status as a
group, militia, or insurgent organization?
J-1 exchange visitor or J-2 dependent in Part 4. Additional
Yes
No
Information for Answers to Item Numbers 18., 19. and 20.
13.
Have you, or any other person included in this application,
EVER served in any prison, jail, prison camp, detention
Part 5. Applicant's Statement, Contact
facility, labor camp, or any other situation that involved
detaining persons?
Information, Certification and Signature
Yes
No
14.
Have you, or any other person included in this application,
NOTE: Select the box for either Item Number 1.a. or 1.b. If
EVER been a member of, assisted in, or participated in
applicable, select the box for Item Number 2.
any group, unit, or organization of any kind in which you
1.a.
I can read and understand English, and have read and
or other persons used any type of weapon against any
understand each and every question and instruction
person or threatened to do so?
Yes
No
on this form, as well as my answer to every question.
15.
Have you, or any other person included in this application,
1.b.
The interpreter named in Part 6. has also read to me
EVER assisted or participated in selling, providing, or
every question and instruction on this form, as well
transporting weapons to any person who to your
as my answer to every question, in
knowledge, used them against another person?
,
Yes
No
a language in which I am fluent. I understand every
16.
Have you, or any other person included in this application,
question and instruction on this form as translated to
EVER received any type of military, paramilitary, or
me by my interpreter, and have provided true and
weapons training?
correct responses in the language indicated above.
Yes
No
17.
Have you, or any other person included in this
2.
I have requested the services of and consented to
application, done anything that violated the terms of the
,
nonimmigrant status you now hold?
Yes
No
who is
is not
an attorney or accredited
18.
Are you, or any other person included in this application,
representative, preparing this form for me.
now in removal proceedings?
Yes
No
Applicant's Certification
If "Yes," provide the following information concerning the
I certify, under penalty of perjury, that the information in my
removal proceedings in Part 4. Additional Information for
form and any document submitted with my form is true and
Answers to Item Numbers 18., 19., and 20. Include the name
correct. Copies of any documents I have submitted are exact
of the person in removal proceedings and information on
photocopies of unaltered original documents, and I understand
jurisdiction, date proceedings began, and status of proceedings.
that USCIS may require that I submit original documents to
19.
Have you, or any other person included in this
USCIS at a later date. Furthermore, I authorize the release of
application, been employed in the United States since last
any information from any and all of my records that USCIS
admitted or granted an extension or change of status?
may need to determine my eligibility for the benefit that I seek.
Yes
No
I furthermore authorize release of information contained in this
If "No," fully describe how you are supporting yourself in
form, in supporting documents, and in my USCIS records, to
Part 4. Additional Information for Answers to Item
other entities and persons where necessary for the
Numbers 18., 19., and 20. Include documentary evidence of
administration and enforcement of U.S. immigration laws.
the source, amount, and basis for any income.
3.a.
Applicant's Signature
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
►
3.b.
Date of Signature
(mm/dd/yyyy)
the employer, weekly income, and whether the employment was
specifically authorized by USCIS.
Form I-539 12/23/16 N
Page 3 of 9
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