Form I-360 Form I-360 Application to File Declaration of Intention

OMB No. 1615-0078; Expires 09/30/2010

N-300, Application to File
Declaration of Intention

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.
Part 1. Information about you. (NOTE: Applicant must complete

For USCIS Use Only
Receipt

Returned

all three pages of this form.)

Family Name

Given Name

Middle Name
Resubmitted

Address - C/O
Street Number and Name
City

Apt. #
State or Province

Country

Zip/Postal Code

Date of Birth (mm/dd/yyyy) Country of Birth

Country of Citizenship

U.S. Social Security # (If any)

A# (If any)

Telephone Number

E-Mail Address (If any)

(

Reloc Sent

)

Reloc Rec'd

Applicant
Interviewed

Part 2. Processing Information.
Date you became a permanent resident (mm/dd/yyyy)
Since you were admitted to the United States as a permanent resident, have you been absent for a
period of six months or longer?
No
Yes Attach a list of departure/arrival dates of all
absences.
Read the information on penalties in the instructions before
Part 3. Signature. completing this section. You must be in the United States when you
file this application. You must sign your name below and also sign
your name in the appropriate places (Signature of Applicant on Pages
2 and 3) of this form.
I desire to declare my intention to become a citizen of the United States. 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 release of any information from my records
that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am
seeking.
Date
Signature

Action Block

Part 4. Signature of person preparing form, if other than above.
(Sign below.)
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 any knowledge.
Signature
Date
Print Your Name

To Be Completed by
Attorney or Representative, if any

Firm Name

Fill in box if G-28 is attached to
represent the applicant.

Firm Address

ATTY State License #
Telephone Number

(

)

E-Mail Address (If any)
Form N-300 (Rev. 09/08/09)Y

Original to be retained by USCIS - Duplicate to be given to:
Family Name

Given Name

Middle Name

Address - C/O
Street Number and Name

Apt. #

City

State or Province

Country

Zip/Postal Code

Date of Birth (mm/dd/yyyy) Country of Birth
A# (If any)

Telephone Number

E-Mail Address (If any)

)

Photograph
Here

Country of Citizenship

U.S. Social Security # (If any)

(

Affix

I am over the age of 18 years, have been lawfully admitted to the United States as a
permanent resident, and am now residing in the United States pursuant to such
admission.

Not valid unless DHS Seal
applied below.

I hereby declare my intention in good faith to become a citizen of the United States and
I certify that the photographs affixed to the original and duplicate hereof are a likeness
of me and were signed by me.
I do swear (or affirm) that the statements I have made and the intentions I have
expressed in this declaration of intention subscribed by me are true to the best of my
knowledge and belief.

Original Copy/Retained
by USCIS

Signature of Applicant

Signature of Authorizing Official

Date

Date

Form N-300 (Rev. 09/08/09)Y Page 2

Original to be retained by USCIS - Duplicate to be given to:
Family Name

Given Name

Middle Name

Address - C/O
Street Number and Name

Apt. #

City

State or Province

Country

Zip/Postal Code

Date of Birth (mm/dd/yyyy) Country of Birth

Photograph
Here

Country of Citizenship

U.S. Social Security # (If any)

A# (If any)

Telephone Number

E-Mail Address (If any)

(

Affix

)

I am over the age of 18 years, have been lawfully admitted to the United States as a
permanent resident, and am now residing in the United States pursuant to such
admission.

Not valid unless DHS Seal
applied below.

I hereby declare my intention in good faith to become a citizen of the United States and
I certify that the photographs affixed to the original and duplicate hereof are a likeness
of me and were signed by me.
I do swear (or affirm) that the statements I have made and the intentions I have
expressed in this declaration of intention subscribed by me are true to the best of my
knowledge and belief.

Duplicate Copy/Given
to Applicant

Signature of Applicant

Signature of Authorizing Official

Date

Date

Form N-300 (Rev. 09/08/09)Y Page 3