Form I-539 - Application To Extend/change Nonimmigrant Status Page 5
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9Part 7. Contact Information, Certification, and
Signature of the Person Preparing this
Application, If Other than the Applicant
(continued)
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Fax Number
6.
Preparer's E-mail Address
7.a.
I am not an attorney or accredited representative but
have prepared this form on behalf of the applicant
and with the applicant's consent.
7.b.
I am an attorney or accredited representative and my
representation of the applicant in this case
(choose one) extends
does not extend
beyond the preparation of this form.
Preparer's Certification
By my signature, I certify, swear or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the applicant. I completed this
form based only on responses the applicant provided to me.
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with every
answer on the form. If the applicant supplied additional
information concerning a question on the form, I recorded it on
the form.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy) ►
Form I-539 12/23/16 N
Page 5 of 9
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