Application to Extend/Change Nonimmigrant Status
USCIS Form I-539
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0003
Applicant: Simon Yochai Ben Haim Ben Hamo Expires: 3/31/2027
Receipt Number: MCT2590003415
Submission Date: 07/09/2025
Part 1. Information About You
1. Your Full Legal Name:
Family Name (Last Name): Ben Haim Ben Hamo
Given Name (First Name): Simon
Middle Name (if applicable): Yochai
2. Alien Registration Number (A-Number)(if any):
3. USCIS Online Account Number (if any):
4. Your U.S. Mailing Address (Safe Address, if applicable)
In Care Of Name (if any):
Street Number and Name: 18944 STRATHERN ST
Apt/Ste/Flr/Number:
City or Town: RESEDA
State: CA
Zip Code: 91335-1150
5. Is your mailing address the same as your physical address?: true
6. Your Current Physical Address
Street Number and Name: 18944 STRATHERN ST
Apt/Ste/Flr/Number:
City or Town: RESEDA
State: CA
Zip Code: 91335-1150
Other Information About You
7. Country of Birth: ISR
8. Country of Citizenship or Nationality: ISR
9. Date of Birth (mm/dd/yyyy): 09/24/2002
10. US Social Security Number (if any):
11. Provide Information About Your Most Recent Entry Into the United States
Date of Last Arrival Into the United States (mm/dd/yyyy): 07/10/2024
Form I-94 Arrival-Departure Record Number: 058236925A4
Passport Number(if any):
Travel Document Number (if any): 34885517
Country of Passport or Travel Document Issuance: ISR
Passport or Travel Document Expiration Date (mm/dd/yyyy): 01/02/2032
12. Current Nonimmigration Status (for example, F-1 student, H-4 Dependent, etc.): B2
Date Status Expires (mm/dd/yyyy): 07/10/2025
Form I-539 Edition 8/28/2024 Page 1 of 5
Select this box if you were granted Duration of Status (D/S): No
Part 2. Application Type
1. I am applying for: Extension of Stay
2. If you are applying for a change of status or change of employer/information medium, complete the following:
I am requesting to change my status or employer/information medium to:
I am requesting the change to be effective on date (mm/dd/yyyy):
3. Number of people included in this application: I am the only applicant.
4. The total number of people (including me) in the application is: (Form I-539A is required for each co-applicant.):
5. The name of the school you will attend (if applicable) as an Academic Student, Vocational Student, or Exchange Visitor.:
6. Your Student and Exchange Visitor Information System (SEVIS) ID Number, if applicable.:
Part 3. Processing Information
1. I/We request that my/our current or requested status be extended until (mm/dd/yyyy): 01/10/2026
2. Is this application based on an extension or change of status already granted to your spouse, child, or parent?: No
3. Is this application based on an extension or change of status already granted to your spouse, child, or parent?:
4. If you answered "Yes" to Item Number 2. or Item Number 3., select the Form type below.: No
5. If you answered "Yes" to Item Number 2. or 3., provide the USCIS Receipt Number:
If the petition or application is pending with USCIS, also provide the following information:
6. First and Last Name of Beneficiary or Applicant:
First Name of Beneficiary or applicant:
Last Name of Beneficiary or applicant:
7. Date Filed (mm/dd/yyyy):
Part 4. Additional Information About the Principal Applicant
1. Current Passport Information
Passport Number:
Country of Passport Issuance:
Passport Expiration Date(mm/dd/yyyy):
2. Physical Address Abroad
Street Number and Name: HaShizaf 1 st
Apt/Ste/Flr/Number: Apt 6
City or Town: Katzrin
Province:
Postal Code: 1290113
Country:
Answer the following questions. If you answer “Yes” to any of the questions in Item Numbers 3. - 15., use the space
provided in Part 8. Additional Information to provide an explanation.
3. Are you an applicant for an immigrant visa?: No
4. Has an immigrant petition EVER been filed for you?: No
5. Have you EVER filed Form I-485, Application to Register Permanent Residence or Adjust Status?: No
6. Have you been arrested or convicted of any criminal offense since last entering the United States?: No
Additional Explanation:
Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
7.a. Acts involving torture or genocide?: No
Additional Explanation:
Form I-539 Edition 8/28/2024 Page 2 of 5
7.b. Killing Any Person?: No
Additional Explanation:
7.c. Intentionally and severely injuring any person?: No
Additional Explanation:
7.d 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?: No
Additional Explanation:
7.e. Limiting or denying any person’s ability to exercise religious beliefs?: No
Additional Explanation:
Have you EVER:
8.a. 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? : No
Additional Explanation:
8.b. Worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation
that involved detaining persons?: No
Additional Explanation:
9. 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 or threatened to use any type of weapon against any person or threatened to do so?: No
Additional Explanation:
10. Have you EVER sold, provided, or transported weapons, or assisted any person in selling, providing, or transporting weapons,
which, you knew or believed would be used against another person?: No
Additional Explanation:
11. Have you EVER received any weapons training, paramilitary training, or other military-type training?: No
Additional Explanation:
12. Have you EVER violated the terms of the nonimmigrant status you now hold?: No
Additional Explanation:
13. Are you now in removal proceedings?: No
Additional Explanation:
14. Have you EVER been employed in the United States since last admitted or granted an extension or change of status?: No
If you answered “No” to Item Number 14., fully describe how you are supporting yourself in Part 8. Additional Information. Include
documentary evidence of the source, amount, and basis for any income.:
If you answered "Yes" to Item Number 14., fully describe any and all periods of employment in Part 8. Additional Information.
Include the name and address of the employer, weekly income, and whether the employment was specifically authorized by USCIS.:
Supporting Self Additional Explanation: I am currently financially supported by my girlfriend who is a United States citizen. She
provides for our household expenses, including rent utilities, food transportation and other necessary living costs during my stay in
the United States. I have not worked and rely entirely on my girlfriend we maintain a stable and responsible financial situation,
ensuring that all obligations and needs are met without issues
Employment Additional Explanation:
15. Are you currently or have you EVER been a J-1 exchange visitor or a J-2 dependent of a J-1 exchange visitor?: No
If you answered “Yes” to Item Number 15., you must provide the dates you maintained status as a J-1 exchange visitor or J-2
dependent in Part 8. Additional Information.:
Form I-539 Edition 8/28/2024 Page 3 of 5
Additional Explanation:
Part 5. Applicant's Contact Information, Certification, and Signature
Applicant’s Contact Information
1. Applicant’s Daytime Telephone Number: 407-912-0433
2. Applicant’s Mobile Telephone Number (if any): 407-912-0433
3. Applicant’s Email Address (if any):
[email protected] Applicant's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted
with my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in
Part 6., understood, all of the responses and information contained in, and submitted with, my application, and that all of the
responses and the information are complete, true, and correct. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my eligibility for an immigration request and to other entities and persons
where necessary for the administration and enforcement of U.S. immigration law.
4. Applicant's Signature: Simon Yochai Ben Haim
Date of Signature (mm/dd/yyyy): 07/09/2025
Part 6. Interpreter’s Contact Information, Certification, and Signature
Interpreter's Full Name
1. Interpreter’s Family Name (Last Name):
Interpreter’s Given Name (First Name):
2. Interpreter’s Business or Organization Name:
Interpreter’s Contact Information
3. Interpreter’s Daytime Telephone Number:
4. Interpreter’s Mobile Telephone Number (if any):
5. Interpreter’s Email Address (if any):
Interpreter's Certification and Signature
I certify, under penalty of perjury, that I am fluent in English and I am fluent in English and , and I have interpreted
every question on the application and Instructions and interpreted the applicant's answers to the questions in that
language, and the applicant informed me that they understood every instruction, question, and answer on the
application.
6. Interpreter’s Signature:
Date of Signature (mm/dd/yyyy):
Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than
the Applicant
Preparer’s Full Name
1. Preparer’s Family Name (Last Name):
Preparer’s Given Name (First Name):
2. Preparer’s Business or Organization Name:
Preparer’s Contact Information
3. Preparer’s Daytime Telephone Number:
4. Preparer’s Mobile Telephone Number (if any):
5. Preparer’s Email Address (if any):
Preparer’s Certification and Signature
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I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express
consent and that all of the responses and information contained in and submitted with the application are complete,
true, and correct and reflects only information provided by the applicant. The applicant reviewed the responses and
information and informed me that they understand the responses and information in or submitted with the application.
6. Preparer’s Signature:
Date of Signature (mm/dd/yyyy):
Part 8. Additional Information
Evidence Items
Original File Name: Visa extension statement.pdf
Category: Written Statements
Original File Name: image.jpg
Category: I-94
Original File Name: image.jpg
Category: I-94
Original File Name: image.jpg
Category: Other Supporting Documents
Original File Name: image.jpg
Category: Other Supporting Documents
Original File Name: image.jpg
Category: Other Supporting Documents
Original File Name: IMG_7044.jpeg
Category: Other Supporting Documents
Form I-539 Edition 8/28/2024 Page 5 of 5
