Application to Extend/Change Nonimmigrant Status
Form I-539
Prepared for
noufah alsubaie
Last Printed On
07/08/2015
Next Steps
1. Read and Follow Application to Extend/Change Nonimmigrant Status Filing Instructions.
2. Sign and Date Your Printed Application.
3. Prepare Photographs and Supporting Documents, as instructed.*
4. Prepare Filing Fee, if necessary.*
5. Attach Photographs, Supporting Documents, and Payment
6. Photocopy Your Signed Application, Photographs, Supporting Documents, Payment and keep the copies for your records.
7. Send Your Original Signed Application, Original Photographs, Copies of Supporting Documents, and Payment to the USCIS to the address listed in the Filing Instructions.
8. Do Not Send This Cover Page or Your Filing Instructions.
* You may or may not have to send photographs, supporting documents, or a filing fee. Your
Form's Filing Instructions will specify everything that is required.
If you need Further Assistance, Please Contact Our Customer Care Team
Monday - Friday, 6:00 AM - 10:00 PM PST
E-mail: cs@immigrationdirect.com (or) Phone: 1-855-544-5095
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Congratulations, noufah, you have reached the final stage of the application process!
Following are step-by-step instructions for completing your application and submitting it to U.S.
Citizenship and Immigration Services (USCIS). These instructions have been customized for you based on the answers you gave on your questionnaire.
Note: Be sure to make a copy of your final application and supporting documents before you send them to USCIS. You will be reminded to do this again later in these instructions.
FINAL STEPS
Step 1 - Review, sign and date your application
Step 2 - Prepare supporting documents
Step 3 - Prepare payment
Step 4 - Photocopy your signed application, supporting documents, and payment
Step 5 - Send completed application and attachments to USCIS
Step 6 - Next steps
Note: Please read all instructions carefully. Any mistakes or omissions will result in a delay and may cause your application to be rejected. If you have any questions about these instructions, please contact
1-855-544-5095, or email cs@immigrationdirect.com.
STEP 1 - REVIEW, SIGN AND DATE YOUR APPLICATION
For this step you will need a printed copy of your Form I-539, Application to Extend/Change
Nonimmigrant Status on paper measuring 8 1/2 inches x 11 inches.
Once you have reviewed the completed application and found it satisfactory, you should sign and date the application as follows:
Find Part 5 of your application.
If you can read and understand English, check the box "I can read and understand English, and have read and understood each and every question and instruction on this form, as well as my answer to every question." If you cannot read and understand English and are using an interpreter, check the box "The interpreter named in Part 6. has also read to me every question and instruction on this form, as well as my answer to www.immigrationdirect.com 2 of 9
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every question, in...."
Find Page 3, Part 5.3.a of your application,
Sign your name in the box labeled "Applicant's Signature".
Find Part 5.3.b of your application,
Write the date in the box labeled "Date of Signature" using the Month/Day/Year format.
For example: If you are signing your application on 8 July, 2015, then you would write 07/08/2015 in the box. If you have not already done so, please sign and date Part 5 now.
If you are using an interpreter, then the interpreter needs to complete Part 6 of your application. The interpreter should specify the language used for interpreting in the space given and provide the requested information, such as his/her name, address, phone number, date and signature.
Note: If you do not sign your application, it will be returned. Please be sure to sign your application before continuing.
In addition to Form I-539, you will find that you have printed Form G-1145, E-Notification of
Application/Petition Acceptance. This form informs USCIS that you would like to receive a text or e-mail notification when your Form I-539 is accepted for processing. You are not required to sign this form.
Place Form G-1145 on top of Form I-539 and staple both forms together.
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STEP 2 - PREPARE SUPPORTING DOCUMENTS
In this step you will prepare your supporting documents.
REQUIRED SUPPORTING DOCUMENTS
Provide a copy of the biographical page of your passport and visa page (if any).
Your answers indicate that you do not have an I-94 card. Per USCIS, you are required to submit a copy of your Form I-94 with your Form I-539. If a copy of your Form I-94 cannot be submitted with this application, you need to include Form I-102, Application for Replacement/Initial Nonimmigrant
Arrival/Departure Document, with the required fee.
Please complete and include Form I-102, Application for Replacement/Initial Nonimmigrant
Arrival/Departure Document. Call 1-855-544-5095 for 24/7 phone support.
Explain the following in a separate sheet and include with your application.
The reason you are requesting an extension of B-1/B-2 status or a change to B-1/B-2 status;
The reason why your extended stay would be temporary, including what arrangements you have made to depart from the United States; and
Any effect the extended stay may have on your foreign employment or residency.
You should also submit any available evidence that you will return to your home country at the end of the requested stay, such as a copy of your return air ticket.
Note: If you do not include all of the documents listed, your application may be delayed or rejected.
Please be sure to include all of the documents listed. Please check off the documents as you prepare them so that you can be sure that you have included all of them.
If you do not have a required document and cannot get a certified copy of the original, please send certification from the person or authority that originally issued the document explaining why it cannot be provided. The USCIS will consider documents such as notarized affidavits in this case.
In addition, please be aware of the following important guidelines when submitting your supporting documents: If you are filing using a name other than shown on the relevant documents, you must file your application with evidence of the legal change, such as a marriage certificate, adoption decree or court order. You do not need to send original documents or certified copies unless instructed to do so.
Photocopies of these documents are acceptable for your initial application. USCIS will not return any original documents that you send. www.immigrationdirect.com 4 of 9
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If the documents requested are not in English, please send English-language translations of the documents. If you submit translated documents, you must also include a certification statement from the translator. This statement should state that the translator is competent to translate and that the translation is correct. The statement should also include the translator’s name, address, date of translation and signature.
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STEP 3 - PREPARE PAYMENT
In this step you will prepare payment for the application fee.
Note: If you do not send payment with your application, your application will be returned.
You must pay your application fee with a personal check, money order, or cashier's check from a U.S. bank in U.S. dollars. DO NOT send cash.
Please write a check, money order, or cashier's check for $620 payable to: U.S. Department of
Homeland Security
Form I-539 (Application to Extend/Change : $290
Nonimmigrant Status) Fee
Form I-102 (Application for Replacement/Initial : $330
Nonimmigrant Arrival/Departure Document) Fee
TOTAL Fee : $620
Note: You do not need to pay the fee for Form I-102 if you are a Nonimmigrant military member in the
U.S. Armed Forces or you are participating in a NATO or Partnership for Peace military program under the SOFA.
STEP 4 - PHOTOCOPY YOUR SIGNED APPLICATION, SUPPORTING
DOCUMENTS, AND PAYMENT
For this step you need your signed Form I-539 application and 1 Form I-102 application, all supporting documents and check or money order. You will also need a large envelope or folder to hold your copied application and supporting materials. It is important to keep a copy of everything you send to USCIS.
Photocopy each page of your completed application and supporting documents, including the fee payment, and place them in the envelope. These copies are for your records only. DO NOT
Send them to USCIS.
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STEP 5 - SEND YOUR COMPLETED FORM I-539 APPLICATION TO USCIS
You are almost finished! For this step you'll need your original completed and signed Form I539 application and 1 Form I-102 application, your supporting documents and a check or money order. In addition you will need Form G-1145. You'll also need an envelope large enough to hold everything.
Write your return address (the address where you live or where you receive your mail) in the upper left corner of the large envelope.
Using a paper-clip, attach your payment to the first page of your Form I-539 application.
Place your Form I-102 and supporting documents under your Form I-539 application.
Put your Form I-539 and Form I-102 application and supporting documents into the large envelope.
Mail your application by certified mail or courier service and request a return receipt. Send your application to:
For U.S. Postal Service (USPS) deliveries:
USCIS
P.O. Box 660166
Dallas, TX 75266
For Express mail and courier deliveries:
USCIS
ATTN: I-539
2501 S. State Highway 121 Business
Suite 400
Lewisville, TX 75067
Please Note: It is important that you file your application as promptly as possible after printing the completed form or forms from our site. USCIS reserves the right to publish updated forms at any time.
The forms printed on our site are guaranteed to be current editions as-of the date that they are printed.
However, Immigration Direct cannot be held responsible for the submission of expired forms due to unreasonable delay in filing on the part of the user. If you expect to delay submitting your application to
USCIS, please be sure to confirm that the form you have printed is still being accepted by USCIS prior to filing. You can check the validity of your form at any time by logging into the Application Support
Center and reprinting your form.
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Note: Applicants are required to notify USCIS of any change of address that occurs while an application is pending. You can notify USCIS of the change by contacting the agency via phone at 1-800-375-5283, or by submitting the change online at https://egov.uscis.gov/crisgwi/go?action=coa.
Lastly, you should also notify the U.S. Postal Service of your address change and have all mail forwarded to your new address.
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STEP 6 - NEXT STEPS
Within 24 hours of accepting your application for processing, USCIS will send you a text and/or e-mail notification that your application has been accepted. The message will provide a receipt number and a brief statement on how to get additional information about the status of your case.
You can expect to receive an official Receipt Notice from USCIS via mail within 30 days of filing your completed Form I-539, Application to Extend/Change Nonimmigrant Status. USCIS will notify you when processing is completed on your case by sending you a Duplicate Approval
Notice on Form I-797.
You can check the status of your case by logging in to www.uscis.gov and entering the receipt number that appears on your USCIS Receipt Notice.
You must wait for USCIS to complete processing of your case. You will receive a final decision on your application via mail. You can check on processing times at www.uscis.gov.
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USCIS
Form I-539
Application to Extend/Change Nonimmigrant Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0003
Expires 04/30/2018
Action Block
Fee Stamp
For USCIS Use Only
Returned
Resubmitted
Received
Relocated
Sent
Remarks:
Granted
Denied
New Class
Still within period of stay
From
/
/
/
S/D to:
/
Place under docket control
Dates:
To
/
/
To Be Completed by an Attorney or Accredited Representative, if any.
Applicant interviewed on
Select this box if G-28 is attached to represent the applicant.
Attorney State License Number:
Part 1. Information About You
Other Information
1.
Alien Registration Number (A-Number)
► A- N / A
6.
USCIS ELIS Account Number (if any)
► N / A
7.
2.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
Country of Birth
SAUDI ARABIA
Country of Citizenship or Nationality
SAUDI ARABIA
8.
Date of Birth
NOUFAH
9.
U.S. Social Security Number (if any)
► N / A
MOHAMMED
10.
Date of Last Arrival Into the United States
(mm/dd/yyyy) ► 02/08/2015
Mailing Address
4.a. In Care Of Name
Provide information about your most recent Form I-94
FARRAJ ALAMANI
4.b. Street Number and Name
4.c. Apt.
11.a. I-94 Arrival-Departure Record Number
Flr.
6
4.d. City or Town
WILKES BARRE
4.e. State PA
4.f.
ZIP Code 18702
11.b. Passport Number M756239
11.c. Travel Document Number N/A
11.d. Country of Issuance for Passport or Travel Document
SAUDI ARABIA
11.e. Expiration Date for Passport or Travel Document
Physical Address
5.b. Apt.
► N / A
92 W RIVER ST
Ste.
5.a. Street Number and Name
(mm/dd/yyyy) ► 11/17/1963
ALSUBAIE
(mm/dd/yyyy) ► 02/04/2019
92 W RIVER ST
12.a. Current Nonimmigrant Status
Ste.
Flr.
6
B-1/B-2
5.c. City or Town
WILKES BARRE
12.b. Expiration Date (mm/dd/yyyy) ► 08/07/2015
5.d. State PA
5.e. ZIP Code 18702
12.c.
Form I-539 04/06/15 N
Check this box if you were granted Duration of Status
(D/S).
Page 1 of 9
Part 2. Application Type (See instructions for fee)
Part 4. Additional Information
I am applying for: (Select one)
If you are the Principal Applicant, provide your current Passport information: 1.
An extension of stay in my current status.
2.a.
A change of status. The new status and effective date
1.a. Country of Issuance for Passport
SAUDI ARABIA
of change. (mm/dd/yyyy) ► N/A
1.b. Expiration Date for Passport
(mm/dd/yyyy) ► 02/04/2019
2.b. The change of status I am requesting is:
N/A
3.
Foreign Home Address
Reinstatement to student status.
2.a. Street Number and Name
Number of people included in this application: (Select one)
4.
I am the only applicant.
5.a.
Members of my family are filing this application with me. 2.b. Apt.
5.b. The total number of people (including me) in the application is: (Complete the supplement for each co-applicant.) 30 ST
Ste.
Flr.
N/A
QAISUMAH
2.d. Province
HAFR ALBATIN
2.e. Postal Code
1
2.c. City or Town
31922
Part 3. Processing Information
2.f.
1.a. I/We request that my/our current or requested status be
Answer the following questions. If you answer "Yes" to any question, describe the circumstances in detail and explain on a separate sheet of paper.
extended until (mm/dd/yyyy) ► 02/06/2016
1.b.
Check this box if you were granted, or are seeking,
Duration of Status (D/S).
2.a. Is this application based on an extension or change of status already granted to your spouse, child, or parent?
Yes
3.
Are you, or any other person included on the application, an applicant for an immigrant visa?
Yes
No
4.
Has an immigrant petition EVER been filed for you or for any other person included in this application?
Yes
No
5.
Has Form I-485, Application to Register Permanent
Residence or Adjust Status, EVER been filed by you or by any other person included in this application?
No
2.b. If "Yes," provide USCIS Receipt Number.
► N / A
3.a. Is this application based on a separate petition or application to give your spouse, child, or parent an extension or change of status?
Yes, filed with this I-539.
No
Yes
6.
Yes, filed previously and pending with USCIS.
3.b. If pending with USCIS, provide USCIS Receipt Number
► N / A
If the petition or application is pending with USCIS, also give the following data:
N/A
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
No
Have you, or any other person included on the application,
EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
7.
Acts involving torture or genocide?
Yes
No
8.
Killing any person?
Yes
No
Intentionally and severely injuring any person?
Yes
Office where petition or application filed:
3.d. City or Town
N/A
3.e. State
10.
N/A
Date Filed
No
9.
3.c. First and last name of petitioner or applicant
3.f.
Country SAUDI ARABIA
(mm/dd/yyyy) ► N/A
Form I-539 04/06/15 N
Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?
Yes
11.
No
No
Limiting or denying any person's ability to exercise religious beliefs?
Yes
No
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20.
Part 4. Additional Information (continued)
12.
Have you, or any other person included on the application,
EVER served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization?
Yes
13.
14.
15.
No
Have you, or any other person included in this application,
EVER served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?
Yes
No
Yes
If "Yes," you must provide the dates you maintained status as a
J-1 exchange visitor or J-2 dependent in Part 4. Additional
Information for Answers to Item Numbers 18., 19. and 20.
Part 5. Applicant's Statement, Contact
Information, Certification and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and have read and understand each and every question and instruction on this form, as well as my answer to every question.
Have you, or any other person included in this application,
EVER assisted or participated in selling, providing, or transporting weapons to any person who to your knowledge, used them against another person?
1.b.
The interpreter named in Part 6. has also read to me every question and instruction on this form, as well as my answer to every question, in
,
No
16.
17.
Have you, or any other person included in this application, done anything that violated the terms of the nonimmigrant status you now hold?
Yes
No
a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated above.
Have you, or any other person included in this application,
EVER received any type of military, paramilitary, or weapons training?
Yes
No
Are you, or any other person included in this application, now in removal proceedings?
Yes
No
If "Yes," provide the following information concerning the removal proceedings in Part 4. Additional Information for
Answers to Item Numbers 18., 19., and 20. Include the name of the person in removal proceedings and information on jurisdiction, date proceedings began, and status of proceedings.
19.
No
Have you, or any other person included in this application,
EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?
Yes
No
Yes
18.
Are you, or any other person included in this application, currently or have you ever been a J-1 exchange visitor or a J-2 dependent of a J-1 exchange visitor?
Have you, or any other person included in this application, been employed in the United States since last admitted or granted an extension or change of status?
Yes
No
If "No," fully describe how you are supporting yourself in
Part 4. Additional Information for Answers to Item
Numbers 18., 19., and 20. Include documentary evidence of the source, amount, and basis for any income.
If "Yes," fully describe the employment in Part 4. Additional
Information for Answers to Item Numbers 18., 19., and 20.
Include the name of the person employed, name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS.
Form I-539 04/06/15 N
2.
I have requested the services of and consented to
, who is is not an attorney or accredited representative, preparing this form for me.
Applicant's Certification
I certify, under penalty of perjury, that the information in my form and any document submitted with my form is true and correct. 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 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 laws.
3.a. Applicant's Signature
3.b. Date of Signature (mm/dd/yyyy) ►
Page 3 of 9
Interpreter Certification
Part 5. Applicant's Statement, Contact Information,
Certification and Signature (continued)
I certify that:
Applicant's Contact Information
I am fluent in English and
, which is the same language provided in Part 5., Item Number 1.b.;
4.
Applicant's Daytime Telephone Number
1-215-6095955
5.
Applicant's Mobile Telephone Number
I have read to this applicant every question and instruction on this form, as well as the answer every question, in the language provided in Part 5., Item Number 1.b.; and
Applicant's E-mail Address
The applicant has informed me that he or she understands every instruction and question on the form, as well as the answer to every question, and the applicant verified the accuracy of every answer..
TALAL2222@HOTMAIL.COM
6.a. Interpreter's Signature
5703282720
6.
Part 6. Contact Information, Statement,
Certification, and Signature of the Interpreter
6.b. Date of Signature (mm/dd/yyyy) ►
Interpreter's Full Name
Part 7. Contact Information, Certification, and
Signature of the Person Preparing this
Application, If Other Than the Applicant
Provide the following information concerning the interpreter:
1.a. Interpreter's Family Name (Last Name)
Preparer's Full Name
1.b. Interpreter's Given Name (First Name)
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
2.
Interpreter's Business or Organization Name (if any)
1.b. Preparer's Given Name (First Name)
Interpreter's Mailing Address
2.
Preparer's Business or Organization Name
3.a. Street Number and Name
3.b. Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
Preparer's Mailing Address
3.a. Street Number and Name
3.e. ZIP Code
Province
3.g. Postal Code
3.h. Country
3.b. Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
3.e. ZIP Code
Province
3.g. Postal Code
Interpreter's Contact Information
4.
5.
3.h. Country
Interpreter's Daytime Telephone Number
Interpreter's E-mail Address
Form I-539 04/06/15 N
Page 4 of 9
Part 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 04/06/15 N
Page 5 of 9
Part 4. (continued) Additional Information for
Answers to Item Numbers 18., 19., and 20.
If you answered "Yes" to Item Number 18. in Part 4. of this form, give the following information concerning the removal proceedings. Include the name of the person in removal proceedings and information on jurisdiction, date proceedings began, and status of proceedings.
1.
If you answered "Yes" to Item Number 19. in Part 4. of this form, fully describe the employment. Include the name of the person employed, name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS.
3.
N/A
N/A
If you answered "Yes" to Item Number 20. in Part 4. of this form, list the name and dates of the person or persons who maintained status as a J-1 exchange visitor or J-2 dependent.
If you answered "No" to Item Number 19. in Part 4. of this form, fully describe how you are supporting yourself. Include the source, amount, and basis for any income.
2.
4.
N/A
SAUDI HEALTH CULTURE MISSION
Form I-539 04/06/15 N
Page 6 of 9
Supplement A. Attach to Form I-539 when more than one person is included in this application.
(List each person separately. Do not include the person named in Form I-539.)
Person Two
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
Person One
2.c. Middle Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
2.d. Date of Birth
2.e. Country of Birth
1.c. Middle Name
1.d. Date of Birth
(mm/dd/yyyy) ►
2.f.
Country of Citizenship or Nationality
(mm/dd/yyyy) ►
1.e. Country of Birth
2.g. U.S. Social Security Number (if any)
►
1.f.
2.h. Alien Registration Number (A-Number)
Country of Citizenship or Nationality
► A1.g. U.S. Social Security Number (if any)
►
2.i.
Date of Arrival (mm/dd/yyyy) ►
2.j.
I-94 Arrival/Departure Record Number
►
1.h. Alien Registration Number (A-Number)
► A1.i.
Date of Arrival (mm/dd/yyyy) ►
1.j.
I-94 Arrival/Departure Record Number
►
2.k. Passport Number
2.l.
Travel Document Number
2.m. Country of Issuance for Passport or Travel Document
1.k. Passport Number
1.l.
Travel Document Number
2.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy) ►
1.m. Country of Issuance for Passport or Travel Document
2.o. Current Nonimmigrant Status
1.n. Expiration Date for Passport or Travel Document
2.p. Expiration Date (mm/dd/yyyy) ►
(mm/dd/yyyy) ►
1.o. Current Nonimmigrant Status
1.p. Expiration Date (mm/dd/yyyy) ►
Form I-539 04/06/15 N
Page 7 of 9
Person Four
Supplement A. Attach to Form I-539 when more than one person is included in this application.
(List each person separately. Do not include the person named in Form I-539.) (continued)
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
Person Three
4.c. Middle Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
4.d. Date of Birth
4.e. Country of Birth
3.c. Middle Name
3.d. Date of Birth
(mm/dd/yyyy) ►
4.f.
Country of Citizenship or Nationality
(mm/dd/yyyy) ►
3.e. Country of Birth
4.g. U.S. Social Security Number (if any)
►
3.f.
Country of Citizenship or Nationality
4.h. Alien Registration Number (A-Number)
► A-
3.g. U.S. Social Security Number (if any)
►
4.i.
Date of Arrival (mm/dd/yyyy) ►
4.j.
I-94 Arrival/Departure Record Number
3.h. Alien Registration Number (A-Number)
►
► A3.i.
Date of Arrival (mm/dd/yyyy) ►
3.j.
I-94 Arrival/Departure Record Number
►
4.k. Passport Number
4.l.
Travel Document Number
4.m. Country of Issuance for Passport or Travel Document
3.k. Passport Number
3.l.
Travel Document Number
4.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy) ►
3.m. Country of Issuance for Passport or Travel Document
4.o. Current Nonimmigrant Status
3.n. Expiration Date for Passport or Travel Document
4.p. Expiration Date (mm/dd/yyyy) ►
(mm/dd/yyyy) ►
3.o. Current Nonimmigrant Status
3.p. Expiration Date (mm/dd/yyyy) ►
Form I-539 04/06/15 N
Page 8 of 9
Person Six
Supplement A. Attach to Form I-539 when more than one person is included in this application.
(List each person separately. Do not include the person named in Form I-539.) (continued)
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
Person Five
6.c. Middle Name
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
6.d. Date of Birth
6.e. Country of Birth
5.c. Middle Name
5.d. Date of Birth
(mm/dd/yyyy) ►
6.f.
Country of Citizenship or Nationality
(mm/dd/yyyy) ►
5.e. Country of Birth
6.g. U.S. Social Security Number (if any)
►
5.f.
6.h. Alien Registration Number (A-Number)
Country of Citizenship or Nationality
► A5.g. U.S. Social Security Number (if any)
►
6.i.
Date of Arrival (mm/dd/yyyy) ►
6.j.
I-94 Arrival/Departure Record Number
►
5.h. Alien Registration Number (A-Number)
► A5.i.
Date of Arrival (mm/dd/yyyy) ►
5.j.
I-94 Arrival/Departure Record Number
►
6.k. Passport Number
6.l.
Travel Document Number
6.m. Country of Issuance for Passport or Travel Document
5.k. Passport Number
5.l.
Travel Document Number
6.n. Expiration Date for Passport or Travel Document
(mm/dd/yyyy) ►
5.m. Country of Issuance for Passport or Travel Document
6.o. Current Nonimmigrant Status
5.n. Expiration Date for Passport or Travel Document
6.p. Expiration Date (mm/dd/yyyy) ►
(mm/dd/yyyy) ►
5.o. Current Nonimmigrant Status
5.p. Expiration Date (mm/dd/yyyy) ►
Form I-539 04/06/15 N
Page 9 of 9
e-Notification of Application/Petition Acceptance
USCIS
Form G-1145
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0109
Expires 09/30/2016
What Is the Purpose of This Form?
Use this form to request an electronic notification (e-Notification) when U.S. Citizenship and Immigration Services accepts your immigration application. This service is available for applications filed at a USCIS Lockbox facility.
General Information
Complete the information below and clip this form to the first page of your application package. You will receive one e-mail and/or text message for each form you are filing.
We will send the e-Notification within 24 hours after we accept your application. Domestic customers will receive an e-mail and/or text message; overseas customers will only receive an e-mail. Undeliverable e-Notifications cannot be resent.
The e-mail or text message will display your receipt number and tell you how to get updated case status information. It will not include any personal information. The e-Notification does not grant any type of status or benefit; rather it is provided as a convenience to customers.
USCIS will also mail you a receipt notice (I-797C), which you will receive within 10 days after your application has been accepted; use this notice as proof of your pending application or petition.
USCIS Privacy Act Statement
AUTHORITIES: The information requested on this form is collected pursuant to section 103(a) of the Immigration and Nationality
Act, as amended INA section 101, et seq.
PURPOSE: The primary purpose for providing the information on this form is to request an electronic notification when USCIS accepts immigration form. The information you provide will be used to send you a text and/or email message.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information may prevent
USCIS from providing you a text and/or email message receipting your immigration form.
ROUTINE USES: The information provide on this form will be used by and disclosed to DHS personnel and contractors in accordance with approved routine uses, as described in the associated published system of records notices [DHS-USCIS-007 Benefits Information System and DHS-USCIS-001 - Alien File (A-File) and Central Index System (CIS), which can be found at www.dhs.gov/privacy]. The information may also be made available, as appropriate for law enforcement purposes or in the interest of national security.
Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
3 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts
Avenue, NW, Washington, DC 20529-2140. OMB No. 1615-0109. Do not mail your completed Form G-1145 to this address.
Complete this form and clip it on top of the first page of your immigration form(s).
Applicant/Petitioner Full Last Name
ALSUBAIE
Applicant/Petitioner Full First Name
NOUFAH
Applicant/Petitioner Full Middle Name
MOHAMMED
E-mail Address
Mobile Phone Number (Text Message)
N/A
1-215-6095955
Form G-1145 09/15/14 Y
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