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Supplemental Information For Application To Extend/Change Nonimmigrant Status
Supplemental Information For Application To Extend/Change Nonimmigrant Status
To be completed by an Select this box if Attorney State Bar Number Attorney or Accredited Representative
attorney or BIA- Form G-28 is (if applicable) USCIS Online Account Number (if any)
accredited attached.
representative (if any).
2. Date of Birth (mm/dd/yyyy) 14. USCIS Online Account Number (if any)
►
3. Country of Birth
Provide Information About Your Most Recent Entry Into the Any Federal, State, local or tribal cash assistance
United States for income maintenance
Supplemental Security Income (SSI)
8. Form I-94 Arrival-Departure Record Number
► Temporary Assistance for Needy Families
(TANF)
9. Passport Number General Assistance (GA)
Date Benefit or Coverage Ended or Expires I am a child currently residing abroad who entered
(mm/dd/yyyy) the United States with a nonimmigrant visa to attend
an N-600K, Application for Citizenship and Issuance
of Certificate Under INA Section 322 interview.
C. Type of Benefit
None of the above statements apply to me.
benefits, dates of receipt, and any other relevant information 3.b. Apt. Ste. Flr.
provided to the agency for the purpose of obtaining such public
benefit, to the extent permitted by law. I also authorize SSA, 3.c. City or Town
USDA, HHS, HUD, and any other U.S. Government agency to
provide any additional data and information to USCIS, to the 3.d. State 3.e. ZIP Code
extent permitted by law.
3.f. Province
I authorize custodians of records and other sources of
information pertaining to my request for or receipt of public 3.g. Postal Code
benefits to release information regarding my request for and/or
receipt of public benefits, upon the request of the investigator, 3.h. Country
special agent, or other duly accredited representative of any
Federal agency authorized above, regardless of any previous
agreement to the contrary.
Interpreter's Contact Information
I understand that the information released by records custodians
and sources of information is for official use by the Federal 4. Interpreter's Daytime Telephone Number
Government, that the U.S. Government will use it only to
review if I have received public benefits in regards to my
eligibility for immigration benefits and to enforce immigration 5. Interpreter's Mobile Telephone Number (if any)
laws, and that the U.S. Government may disclose the
information only as authorized by law.
6. Interpreter's Email Address (if any)
Applicant's Signature
6.a. Applicant's Signature
Interpreter's Certification
I certify, under penalty of perjury, that:
6.b. Date of Signature (mm/dd/yyyy)
I am fluent in English and ,
NOTE TO ALL APPLICANTS: If you do not completely fill which is the same language specified in Part 4., Item Number
out this form or fail to submit required documents listed in the 1.b., and I have read to this applicant in the identified language
Instructions, USCIS may deny the Form I-539 filed on your every question and instruction on this form and his or her
behalf. 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 Certification, and has verified
Part 5. Interpreter's Contact Information, the accuracy of every answer.
Statement, Certification, and Signature
Interpreter's Signature
Provide the following information about the interpreter you used
to complete Form I-539A if he or she is different from the 7.a. Interpreter's Signature
interpreter used to complete the Form I-539 filed on your behalf.
Preparer's Certification
2. Preparer's Business or Organization Name
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
Preparer's Mailing Address she understands all of the information contained in, and
submitted with, his or her form, including the Applicant's
3.a. Street Number Declaration and Certification, and that all of this information
and Name is complete, true, and correct. I completed this form based only
3.b. Apt. Ste. Flr. on information that the applicant provided to me or authorized
me to obtain or use.
3.c. City or Town
Preparer's Signature
3.d. State 3.e. ZIP Code
8.a. Preparer's Signature
3.f. Province
3.h. Country
6.d.
3.d.
7.d.
4.d.