Change/Extension of Status Questionnaire

1. Information about you

Name

First

Middle

Last

Home Phone Number

Cell Phone Number

Email

Current US Address

Address Line 1

Address Line 2

City

State

Zip Code

Foreign Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Alien Number (USCIS Number or A#, if any)

Social Security Number (SSN, if any)

Birth Location (City, State, Country)

Country of Citizenship or Nationality

Date of Birth

Date of Last Arrival

I-94 Number

Passport Number

Passport Country of Issuance

Passport Expiration Date

Current Nonimmigrant Visa Status

Date Current Visa Status Expires

2. Additional questions about you

Are you an applicant for an immigrant visa?

Has an immigrant petition ever been filed for you?

Have you ever filed an I-485 Adjustment of Status application?

Have you ever been arrested or convicted of any criminal offense since last entering the United States?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving torture or genocide?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in killing any person?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in intentionally and severely injuring any person?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in engaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in engaging in limiting or denying any person's ability to exercise religious beliefs?

Have you ever served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, insurgent organization, or any other armed group?

Have you ever worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?

Have you 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 person or threatened to do so?

Have you ever assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person?

Have you ever received any type of military, paramilitary, or weapons training?

Have you done anything that violated the terms of the nonimmigrant status you now hold?

Are you now in removal proceedings?

Have you been employed in the United States since last admitted or granted an extension or change of status?

Are you currently or have you ever been a J-1 exchange visitor or a J-2 dependent of a J-1 exchange visitor?

3. Enter the information of the person submitting this questionnaire.

Name *

Email *

Change/Extension of Status Questionnaire

For Nonimmigrant Visa Status Applications

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