| Candidate Information | | Title | Immigration Services United States | | Target Location | US-TN-Antioch |
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Click here or scroll down to respond to this candidateApplication to Extend/Change Nonimmigrant StatusDepartment of Homeland SecurityU.S. Citizenship and Immigration ServicesUSCISForm I-Street Address
OMB No. Street Address -0003Expires 12/31/2024For USCIS Use Only Fee Stamp Action BlockReturnedResubmittedRelocatedRemarks:ReceivedSentGrantedNew ClassFrom / / /DeniedStill within period of stayS/D to:Dates:To be completed by an Attorney or AccreditedRepresentative (if any).To / / /Select this box if Form G-28 is attached.Place under docket controlAttorney State Bar Number(if applicable)Applicant interviewed onAttorney or Accredited RepresentativeUSCIS Online Account Number (if any)START HERE - Type or print in black ink.Part 1. Information About YouYour Full NameU.S. Physical Address5.a. Street Numberand Name1.a. Family Name(Last Name) 5.b.1.b. Given Name(First Name) 5.c.1.c. Middle Name 5.d.2. Alien Registration Number (A-Number) (if any)Apt. Ste.City or TownState 5.e.Flr.ZIP CodeA-3. USCIS Online Account Number (if any)Other Information About You6. Country of Birth7. Country of Citizenship or NationalityU.S. Mailing Address4.a. In Care Of Name (if any) 8.9.4.b. Street Numberand NameDate of Birth (mm/dd/yyyy)U.S. Social Security Number (if any)Apt. Ste. Flr.10. Date of Last Arrival Into the United States (mm/dd/yyyy)4.d. City or Town4.e. State 4.f. ZIP Code(USPS ZIP Code Lookup)Provide Information About Your Most Recent Entry Into theUnited States11. Form I-94 Arrival-Departure Record Number12. Passport NumberForm I-539 Edition 05/31/22 Page 1 of 7Part 1. Information about You (continued)2.b. If you answered "Yes" to Item Number 2.a., provideUSCIS Receipt Number.13. Travel Document Number14.a. Country of Passport or Travel Document Issuance3.a. Is this application based on a separate petition or applicationto provide your spouse, child, or parent an extension orchange of status?14.b. Passport or Travel Document Expiration Date(mm/dd/yyyy)15.a. Current Nonimmigrant Status (e.g. F-1 student, H-4dependent, etc.) 3.b.Yes, filed with this Form I-539. NoYes, filed previously and pending with U.S.Citizenship and Immigration Services (USCIS).If pending with USCIS, provide USCIS Receipt Number.15.b. Expiration Date (mm/dd/yyyy)If the petition or application is pending with USCIS, alsoprovide the following information:16. Select this box if you were granted Duration of Status(D/S).4. First and Last Name of Petitioner or ApplicantPart 2. Application Type 5.Date Filed (mm/dd/yyyy)I am applying for (select only one box):1. Reinstatement to student status.Part 4. Additional Information About theApplicantAn extension of stay in my current status.A change of status.Provide Your Current Passport Information (if different fromPart 1.)3.b. New status and effective date of change (mm/dd/yyyy) 1.a.1.b.3.c. The change of status I am requesting is:Passport NumberCountry of Passport Issuance1.c. Passport Expiration Date (mm/dd/yyyy)Number of people included in this application (select only onebox):4. I am the only applicant.Physical Address Abroad5.a. Members of my family are filing this application withme. 2.a.Street Numberand Name5.b. The total number of people (including me) in the 2.b. Apt.application is: (Complete the supplement for each co-Ste. Flr.applicant.)Part 3. Processing Information1. I/We request that my/our current or requested status beextended until (mm/dd/yyyy):2.a. Is this application based on an extension or change ofstatus already granted to your spouse, child, or parent?2.c. City or Town2.d. Province2.e. Postal Code2.f. CountryAnswer the following questions. If you answer Yes to any ofYes No the questions in Item Numbers 3. - 15., use the space providedin Part 8. Additional Information to provide an explanation.Form I-539 Edition 05/31/22 Page 2 of 7Part 4. Additional Information About theApplicant (continued)3. Are you, or any other person included on the application,10. Have you, or any other person included in thisapplication, EVER assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person?an applicant for an immigrant visa? Yes NoYes No4. Has an immigrant petition EVER been filed for you or forany other person included in this application?11. Have you, or any other person included in thisapplication, EVER received any type of military,Yes No5. Has Form I-485, Application to Register PermanentResidence or Adjust Status, EVER been filed by you or 12.by any other person included in this application?Yes Noparamilitary, or weapons training? Yes NoHave you, or any other person included in this application, done anything that violated the terms of thenonimmigrant status you now hold? Yes No6. Have you, or any other person included in this application,EVER been arrested or convicted of any criminal offense since last entering the United States? Yes No13. Are you, or any other person included in this application,now in removal proceedings? Yes NoHave you, or any other person included on the application, EVER ordered, incited, called for, committed, assisted, helpedwith, or otherwise participated in any of the following:If you answered "Yes" to Item Number 13., provide the following information concerning the removal proceedings in the space provided in Part 8. Additional Information. Include the name of the person in removal proceedings and information7.a. Acts involving torture or genocide? Yes Noon jurisdiction, date proceedings began, and status ofproceedings.7.b. Killing any person? Yes No 14.Have you, or any other person included in thisapplication, been employed in the United States since last7.c. Intentionally and severely injuring any person?Yes Noadmitted or granted an extension or change of status?Yes No7.d. Engaging in any kind of sexual contact or relations withany person who did not consent or was unable to consent,If you answered "No" to Item Number 14., fully describe howyou are supporting yourself in Part 8. Additional Information.or was being forced or threatened? Yes No7.e. Limiting or denying any person's ability to exerciseInclude documentary evidence of the source, amount, and basisfor any income.religious beliefs?Yes NoIf you answered "Yes" to Item Number 14., fully describe theemployment in Part 8. Additional Information. Include theHave you, or any other person included on the application,EVER:name of the person employed, name and address of the employer, weekly income, and whether the employment was8.a. Served in, been a member of, assisted, or participated in anymilitary unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, insurgentorganization, or any other armed group? Yes No8.b. Worked, volunteered, or otherwise served in any prison,jail, prison camp, detention facility, labor camp, or anyother situation that involved detaining persons?Yes No9. Have you, or any other person included in this application,EVER been a member of, assisted, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any personor threatened to do so? Yes Nospecifically authorized by USCIS.15. Are you, or any other person included in this application, currently or have you ever been a J-1 exchange visitor ora J-2 dependent of a J-1 exchange visitor?Yes NoIf you answered "Yes" to Item Number 15., you must provide the dates you maintained status as a J-1 exchange visitor or J-2dependent in Part 8. Additional Information.Form I-539 Edition 05/31/22 Page 3 of 7NJUGUNAKERENWANJIRU12/01/200011/6/2022KENYANKENYA782098018NC28741HIGHLANDS137 south 4th street,NC111220488A3Ak103487401/20/203211/08/2023KENYA137 south 4th street,NCNORTH CAROLINAHIGHLANDSUNITED STATES OF AMERICA28741AK1034874J1 - EXCHANGE VISITOR - OTHERS1F1 - STUDENT -ACADEMICS11/09/2023 |
