Form I-539A Edition 04/01/24 Page 1 of 4

 Supplemental Information for Application to 

Extend/Change Nonimmigrant Status 

Department of Homeland Security 

U.S. Citizenship and Immigration Services

USCIS 

Form I-539A 

OMB No. 1615-0003 

Expires 02/28/2027

Part 2. Information About You

1.a. Family Name 

(Last Name)

1.b. Given Name 

(First Name)

1.c. Middle Name

7. Date of Arrival (mm/dd/yyyy) 

► A6. Alien Registration Number (A-Number) (if any)

8. Form I-94 Arrival-Departure Record Number

►

Select this box if 

Form G-28 is 

attached.

Attorney State Bar Number 

(if applicable)

Attorney or Accredited Representative 

USCIS Online Account Number (if any)

To be completed by an 

attorney or BIAaccredited 

representative (if any).

9. Passport Number

10. Travel Document Number

► START HERE - Type or print in black ink.

Attach to Form I-539 when more than one person is included in 

the Form I-539 application. List each person on a separate 

Form I-539A. Do not include the person named in Form I-539.

2. Date of Birth (mm/dd/yyyy)

3. Country of Birth

4. Country of Citizenship or Nationality

►

5. U.S. Social Security Number (if any)

Provide Information About Your Most Recent Entry Into the 

United States

11.a. Country of Passport or Travel Document Issuance

Provide Your Current Passport Information (if different from 

Item Number 9.)

13.a. Passport Number

14. USCIS Online Account Number (if any)

►

Part 3. Applicant's Statement, Contact 

Information, Declaration, Certification and 

Signature

NOTE: Read the Penalties section of the Form I-539 and 

Form I-539A Instructions before completing this section.

I can read and understand English, and I have read 

and understand every question and instruction on this 

form and my answer to every question.

1.a.

Applicant's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If 

applicable, select the box for Item Number 2.

1.b. The interpreter named in Part 4. read to me every 

question and instruction on this form and my answer 

to every question in

a language in which I am fluent, and I understood 

everything. 

,

13.b. Country of Passport Issuance

13.c. Passport Expiration Date 

(mm/dd/yyyy)

At my request, the preparer named in Part 5., 

,

2.

prepared this form for me based only upon 

information I provided or authorized. 

11.b. Passport or Travel Document Expiration Date 

(mm/dd/yyyy)

12.a. Current Nonimmigrant Status

12.b. Expiration Date (mm/dd/yyyy) 

Part 1. Information About the Person Filing 

Form I-539

1.a. Family Name 

(Last Name)

1.b. Given Name 

(First Name)

1.c. Middle Name
Form I-539A Edition 04/01/24 Page 2 of 4

Part 3. Applicant's Statement, Contact 

Information, Declaration, Certification and 

Signature (continued)

3. Applicant's Daytime Telephone Number

5. Applicant's Email Address (if any)

4. Applicant's Mobile Telephone Number (if any)

Applicant's Contact Information

Applicant's Declaration and Certification

Copies of any documents I have submitted are exact 

photocopies of unaltered, original documents, and I understand 

that USCIS may require that I submit original documents to 

USCIS at a later date. Furthermore, I authorize the release of 

any information from any and all of my records that USCIS 

may need to determine my eligibility for the immigration 

benefit that I seek.

I furthermore authorize release of information contained in this 

form, in supporting documents, and in my USCIS records, to 

other entities and persons where necessary for the 

administration and enforcement of U.S. immigration law.

I understand that USCIS will require me to appear for an 

appointment to take my biometrics (fingerprints, photograph, 

and/or signature) and, at that time, I will be required to sign an 

oath reaffirming that:

1) I reviewed and understood all of the information 

contained in, and submitted with, my form; and

2) All of this information was complete, true, and correct 

at the time of filing. 

I certify, under penalty of perjury, that all of the information in 

my form and any document submitted with it were provided or 

authorized by me, that I reviewed and understand all of the 

information contained in, and submitted with, my form and that 

all of this information is complete, true, and correct.

6.b. Date of Signature (mm/dd/yyyy) 

6.a. Applicant's Signature

NOTE TO ALL APPLICANTS: If you do not completely fill 

out this form or fail to submit required documents listed in the 

Instructions, USCIS may deny the Form I-539 filed on your 

behalf.

Applicant's Signature

Part 4. Interpreter's Contact Information, 

Statement, Certification, and Signature

1.b. Interpreter's Given Name (First Name)

1.a. Interpreter's Family Name (Last Name)

2. Interpreter's Business or Organization Name (if any)

Interpreter's Full Name

Provide the following information about the interpreter you 

used to complete Form I-539A if he or she is different from the 

interpreter used to complete the Form I-539 filed on your 

behalf.

3.h.

Interpreter's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

3.g. Postal Code 

Street Number 

and Name

3.a.

Country 

3.b. Apt. Ste. Flr.

3.f. Province 

 Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number

6. Interpreter's Email Address (if any)

5. Interpreter's Mobile Telephone Number (if any)

which is the same language specified in Part 3., Item Number 

1.b., and I have read to this applicant in the identified language 

every question and instruction on this form and his or her 

answer to every question. The applicant informed me that he or 

she understands every instruction, question, and answer on the 

form, including the Applicant's Declaration and 

Certification, and has verified the accuracy of every answer.

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and , 

(USPS ZIP Code Lookup)
Form I-539A Edition 04/01/24 Page 3 of 4

3.h.

3.g. Postal Code 

Country 

3.f. Province 

 Preparer's Contact Information

4. Preparer's Daytime Telephone Number

6. Preparer's Email Address (if any)

5. Preparer's Mobile Telephone Number (if any)

Preparer's Mailing Address

3.c. City or Town

3.d. State 3.e. ZIP Code

Street Number 

and Name

3.a.

3.b. Apt. Ste. Flr.

Part 4. Interpreter's Contact Information, 

Statement, Certification, and Signature 

(continued)

7.b. Date of Signature (mm/dd/yyyy)

7.a. Interpreter's Signature

Interpreter's Signature

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

Part 5. Contact Information, Declaration, and 

Signature of the Person Preparing this 

Application, if Other Than the Applicant

2. Preparer's Business or Organization Name

Provide the following information about the preparer you used 

to complete Form I-539A if he or she is different from the 

preparer used to complete the Form I-539 filed on your behalf.

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.a.

7.b.

preparation of this form.

I am an attorney or accredited representative and my 

representation of the applicant in this case

extends does not extend beyond the 

 Preparer's Statement

NOTE: If you are an attorney or accredited representative, 

you may need to submit a completed Form G-28, Notice of 

Entry of Appearance as Attorney or Accredited Representative, 

with this form.

By my signature, I certify, under penalty of perjury, that I 

prepared this form at the request of the applicant. The applicant 

then reviewed this completed form and informed me that he or 

she understands all of the information contained in, and 

submitted with, his or her form, including the Applicant's 

Declaration and Certification, and that all of this information 

is complete, true, and correct. I completed this form based only 

on information that the applicant provided to me or authorized 

me to obtain or use.

 Preparer's Certification

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

 Preparer's Signature
Form I-539A Edition 04/01/24 Page 4 of 4

Part 6. Additional Information

If you need extra space to provide any additional information 

within this form, use the space below. If you need more space 

than what is provided, you may make copies of this page to 

complete and file with this application or attach a separate sheet 

of paper. Type or print your name and A-Number (if any) at the 

top of each sheet; indicate the Page Number, Part Number, 

and Item Number to which your answer refers; and sign and 

date each sheet.

A-Number (if any)

► A3.a.

2.

Page Number 3.b. Part Number 3.c. Item Number

3.d.

Page Number Part Number Item Number

1.b. 

1.c.

1.a. Family Name 

(Last Name) 

Given Name 

(First Name) 

Middle Name

4.b. 4.c.

4.d.

4.a.

5.a. Page Number Part Number Item Number

Page Number

5.b.

Part Number

5.c.

Item Number

5.d.

Page Number Part Number Item Number

6.d.

6.a. 6.b. 6.c.

7.a. 7.b. 7.c.

7.d.