EFTA00525329.pdf

OMB No. 1615-0003: Expires 02/29/2012 Department of Homeland Security U.S. Citizenship and Immigration Services I-539, Application to Extend/ Change Nonimmigrant Status START HERE - Please type or print in blue or black ink Part 1. Information About You Family Name (Last Name) Given Name (First Name) Middle Name SHULIAK Karyna n/a Address - In care of - Street Number and Name Apt. himber City New York State NY Zip Code 10065 Daytime Phone Number Country of Birth Belarus Country of Citizenship Belarus Date of Birth (mm/dcVyyyy) U. S. Social Security # (if any) A-Number (if any) Date of Last Arrival 07/06/2010 Into the U.S. b" Villi Current Nonimmigrant Status I-589 Expires on (mm/dd/yyyy) Part 2. Application Type (See instructions for fee) 1. I am applying for: (Check one) a. An extension of stay in my current status. b. A change of status. The new status I am requesting is: Reinstatement to student status. c. 2. Number of people included in this application: (Check one) a. Q I am the only applicant. b. K Members of my family are filing this application with me. The total number of people (including me) in the application is: (Complete the supplement for each co-applicant.) Part 3. Processing Information 1. I/We request that my/our current or requested status be extended until (mmtdd/yyyy): Mtration of s 2. Is this application based on an extension or change of status already granted to your spouse, child, or parent? NI No K Yes. USCIS Receipt # 3. gthis application based on a separate petition or application to give your spouse, child, or parent an extension or change of status?El No K Yes, filed with this I-539. K Yes, filed previously and pending with USCIS. Receipt #: 4. If you answered "Yes" to Question 3, give the name of the petitioner or applicant: If the petition or application is pending with USCIS, also give the following data: Office filed at Filed on (nonAkl/yyyy) Part 4. Additional Information L. For applicant #1, provide passport information: Country of Issuance: Belarus 2. Foreign Address: Street Number and Name Valid to: (mnikkl/yyyy) 05/31/2014 Apt. Number City or Town Minsk Coun ry RP S' State or Province Minsk Zip/Postal Code 220053 For USCIS (Ice Only Returned Date Resubmitted Date Reloc Sent Date Reloc Reed Date K Applicant Interviewed on Date Receipt K Extension Gn rated to (Date): Change of Status/Edension Granted New Class: From (Date): To (Date): If Denied: K Still within period of stay K S/D to: K Place under docket control Remarks: Action Block z To Be Completed by Attorney or Representative, If any Fill in box if O-28 is attached to represent the applicant. ATTY State License # iii llI II Il III II Forml-539 (10/07/11)Y EFTA00525329 3. Answer the following questions. If you answer "Yes" to any question, describe the circumstances in detail and explain on a separate sheet of paper. Yes No a. Are you, or any other person included on the application, an applicant for an immigrant visa? O N b. Has an immigrant petition ever been filed for you or for any other person included in this application? K N c. 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? O N d. I. 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? d. 2. Have you EVER ordered, incited, called for, commited. assisted, helped with, or otherwise participated in any of the following: (a) Acts involving torture or genocide? (b) Killing any person? (c) Intentionally and severely injuring any person? (d) Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? (e) Limiting or denying any person's ability to exercise religious beliefs? d. 3. Have you EVER: (a) 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? (b) Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? d. 4. Have you 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? d. 5. Have you EVER assisted or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person? d. 6. Have you EVER received any type of military, paramilitary, or weapons training? O N K a K N O 0 0 0 e. Have you, or any other person included in this application, done anything that violated the terms of the nonimmigrant status you now hold? N K f. Are you, or any other person included in this application, now in removal proceedings? N 0 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? O 0 I. If you answered "Yes" to Question 3f, give the following information concerning the removal proceedings on the attached page entitled "Part 4. Additional information. Page for answers to 3f and 3g." Include the name of the person in removal proceedings and information on jurisdiction, date proceedings began, and status of proceedings. 2. If you answered "No" to Question 3g. fully describe how you are supporting yourself on the attached page entitled "Part 4. Additional information. Page for answers to 3f and 3g." Include the source, amount, and basis for any income. 3. If you answered "Yes" to Question 3g, fully describe the employment on the attached page entitled "Part 4. Additional information. Page for answers to 3f and 3g." Include the name of the person employed, name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS. 1111111111 11 1111 1111911 H 1 11 III IIIIIIIII Form 1-539 (10/07/I I) Y Page 2 EFTA00525330 Yes No h. Are you currently or have you ever been a .1- I exchange visitor or a dependent of a J-I exchange visitor? El If "Yes," you must provide the dates you maintained status as a J-1 exchange visitor or J-2 dependent. Willful failure to disclose this information (or other relevant information) can result in your application being denied. Also, provide proof of your or J-2 status, such as a copy of Form DS-2019, Certificate of Eligibility for Exchange Visitor Status, or a copy of your passport that includes the J visa stamp. Part 5. Applicant's Statement and Signature (Read the information on penalties in the instructions before completing this section. You must file this application while in the United States.) Applicant's Statement (Check One): 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 each question. Each and every question and instruction on this form, as well as my answer to each question, has been read to me by the person named below in , a language in which I am fluent. I understand each and every question and instruction on this form, as well as my answer to each question. Applicant's Signature I certify. under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking. Signature Print your Name Karyna Shuliak E-Mail Address Date Da gime Tele hone Number NOTE: If you do not completely"! out this form or fail to submi required documents listed in the instructions, you may not be found eligible for the requested benefit and this application may be denied. Part 6. Interpreter's Statement Language used: I certify that I am fluent in English and the above-mentioned language. I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as well as the answer to each question. Signature Print Your Name Date Firm Name (if applicable) Daytime Telephone Number (Area Code and Number) Address Fax Number (Area Code and Number) E-Mail Address IIIIIIIIIII11111111111111 1111111 1 1111 1 Form 1-539 (10/07!11) Y Page 3 EFTA00525331 Part 7. Signature of Person Preparing Form, if Other Than Above (Sign Below) Signature Print Your Name Date Firm Name (if applicable) Daytime Telephone Number (Area Code and Number) Address Fax Number (Area Code and Number) E-Mail Address I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge. Part 4. (Continued) Additional Information. (Page 2 for answers to 3f and 3g.) If you answered "Yes" to Question 3f in Part 4 on Page 3 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. n/a If you answered "No" to Question 3g in Part 4 on Page 3 of this form, fully describe how you are supporting yourself. Include the source. amount and basis for any income. If you answered "Yes" to Question 3g in Part 4 on Page 3 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. Form 1-539 (10/07/11)Y Page 4 EFTA00525332 Supplement -1 Attach to Form I.539 when more than one person is included in the petition or application. (List each person separately. Do not include the person named in Form 1-539.) Family Name (Last Name) n/a Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (if any) A-Number (if any) Date of Arrival (mm/dd/yyyy) I.94 Number Current Nonimmigrant Status: Expires on (mm/dd/yyyy) Country Where Passport Issued Expiration Date (mm/dd/yyyy) Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (if any) A-Number (if any) Date of Arrival (mm/dd/yyyy) I.94 Number Current Nonimmigrant Status: Expires on (mm/dd/yyyy) Country Where Passport Issued Expiration Date (mm/dd/yyyy) Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth Inunkid/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (if any A-Number (if any) Date of Arrival (mm/dd/yyyy) I.94 Number Current Nonimmigrant Status: Expires on (mm/dd/yyyy) Country Where Passport Issued Expiration Date (mm/dd/yyyy) Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (if any) A-Number (if any) Date of Arrival (mm/dd/yyyy) I-94 Number Current Nonimmigrant Status: Expires on (mm/dd/yyyy) Country Where Passport Issued Expiration Date (mm/dd/yyyy) Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (if any) A-Number (if any) Date of Arrival (mm/dd/yyyy) I.94 Number Current Nonimmigrant Status: Expires on (mm/dd/yyyy) Country Where Passport Issued Expiration Date (mm/dd/yyyy) If you need additional space, attach a separate sheet of paper. Place your name. A-Number, if any, date of birth, form manber. and application date at the top of the sheet of paper. Form I-539 (I 0/07/II ) Y Page 5 EFTA00525333