Form I-539A 02/04/19 Supplemental Information for Application to Extend/Change Nonimmigrant Status Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form I-539A OMB No. 1615-0003 Expires 08/31/2020 Part 2. Information About You1.a.Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name7.Date of Arrival (mm/dd/yyyy) Page 1 of 4A-Alien Registration Number (A-Number) (if any)6.Form I-94 Arrival-Departure Record Number8. 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 BIA- accredited representative (if any). Passport Number9.Travel Document Number10.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.Date of Birth (mm/dd/yyyy)2.Country of Birth3.4.Country of Citizenship or NationalityU.S. Social Security Number (if any)5.Provide Information About Your Most Recent Entry Into the United States11.a.Country of Passport or Travel Document IssuanceProvide Your Current Passport Information (if different from Item Number 9.)Passport Number13.a. USCIS Online Account Number (if any)14. Part 3. Applicant's Statement, Contact Information, Declaration, Certification and SignatureNOTE: 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 StatementNOTE: Select the box for either Item Number 1.a. or 1.b.240 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)Current Nonimmigrant Status12.a.Expiration Date (mm/dd/yyyy) 12.b. Part 1. Information About the Person Filing Form I-5391.a.Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name American LegalNet, Inc. www.FormsWorkFlow.com Form I-539A 02/04/19 Page 2 of 4 Part 3. Applicant's Statement, Contact Information, Declaration, Certification and Signature (continued)Applicant's Daytime Telephone Number3. Applicant's Email Address (if any)5.Applicant's Mobile Telephone Number (if any) 4. Applicant's Contact Information Applicant's Declaration and CertificationCopies 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 seekI 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; and2) 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.Date of Signature (mm/dd/yyyy) 6.b.Applicant's Signature6.a. 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 Interpreter's Given Name (First Name)1.b. Interpreter's Family Name (Last Name)1.a. Interpreter's Business or Organization Name (if any)2. Interpreter's Full NameProvide 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 Address3.c.City or Town 3.d.State3.e.ZIP Code3.g.Postal Code Street Number and Name3.a. Country 3.b. Ste. Flr. Apt. 3.f.Province Interpreter's Contact Information 4.Interpreter's Daytime Telephone NumberInterpreter's Email Address (if any) 6.5.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 CertificationI certify, under penalty of perjury, that: I am fluent in English and , (USPS ZIP Code Lookup ) American LegalNet, Inc. www.FormsWorkFlow.com Form I-539A 02/04/19 Page 3 of 43.h.3.g.Postal Code Country 3.f.Province Preparer's Contact Information4.Preparer's Daytime Telephone Number6.Preparer's Email Address (if any) 5.Preparer's Mobile Telephone Number (if any) Preparer's Mailing Address3.c.City or Town 3.d.State3.e.ZIP CodeStreet Number and Name3.a. 3.b. Ste. Flr. Apt. Part 4. Interpreter's Contact Information, Statement, Certification, and Signature (continued) Date of Signature (mm/dd/yyyy)7.b.Interpreter's Signature7.a. Interpreter's Signature Preparer's Full Name1.a. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)1.b. Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Preparer's Business or Organization Name2.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 extendsdoes not extendbeyond the Preparer's StatementNOTE: 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.240 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 Certification8.a. Preparer's Signature 8.b.Date of Signature (mm/dd/yyyy) Preparer's Signature American LegalNet, Inc. www.FormsWorkFlow.com Form I-539A 02/04/19 Page 4 of 4 Part 6. Additional InformationIf 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 applicat