N-300 Form TOC Revised

N-300, Application to File Declaration of Intention

Form Table of Change

OMB RIN 1615-0078

03/15/2013

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1 OMB No.	OMB No. 1615-0078	OMB No. 1615-0078; Expires 01/31/2012
Page 1	START HERE – please type or print in black ink.	Print or type all your answers fully and accurately in black ink. Write “N/A” if an item is not applicable. Write “None” if the answer is none. Failure to answer all of the questions may delay your Form N-300. NOTE: You must complete all portions of the form (four pages).
Page 1	A # (If any)	Your A-Number: [move from the middle of the first page and place above the receipt box]
Page 1, For USCIS Use Only	Returned Resubmitted Reloc Sent Relo Rec’d Applicant Interviewed Receipt Action Block To be Completed by Attorney or Representative, if any [text box] Fill in box if G-28 is attached to represent the applicant. ATTY State License #	[same as N-600K format] Bar Code [text box] Date Stamp [text box] Remarks [text box] Action [text box]
Page 1, Part 1. Information About You.	Information about you. 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 Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number ( ) E-Mail Address (If any)	Part 1. Information About You 1. Current Legal Name (do not provide a nickname) Family Name (last name) [text box] Given Name (first name) [text box] Middle Name (if applicable) [text box] 2. U.S. Social Security Number](if any) [text box 3. Date of Birth (mm/dd/yyyy) [text box] 4. Date You Became a Permanent Resident (mm/dd/yyyy) [text box] 5. Country of Birth [text box] 6. Country of Nationality [text box] 7. Home Address Street Number and Name (do not write a P.O. Box in this space unless it is your ONLY address.) Apartment Number [text box] City [text box] County [text box] State [text box] ZIP Code [text box] 8. Mailing Address C/O (in care of name) [text box] Street Number and Name [text box] Apartment Number [text box] City [text box] State [text box] ZIP Code [text box] 9. Daytime Phone Number [text box] Work Phone Number (if any) [text box] Evening Phone Number [text box] Mobile Phone Number (if any) [text box] 10. E-Mail Address (if any) [text box]
Page 1, Part 2. Processing Information.	Part 2. Processing Information. Date you became a permanent resident (mm/dd/yyyy) [text box] Since you were admitted to the United States as a permanent resident, have you been absent for a period of six months or longer?	[Merge Part 2 into Part 1. and maintain heading of Information About You]
Page 1, Part 3. Signature	Part 3. Signature. Read the information on penalties in the instructions before completing this section. You must be in the United State 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.	Part 2. Your Signature (USCIS will reject your Form N-300 if it is not signed.) Read the information on penalties in the instructions before completing this section. You must be in the United States when you file this application. You must sign your name below as well as in Part 4 and Part 5. *** Your Signature [text box] Date (mm/dd/yyyy) [text box]
Page 1, Part 4. Signature of person preparing form, if other than above.	Part 4. Signature of person preparing form, if other than above. 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 Firm Name Firm Address Telephone Number E-Mail Address (If any)	Part 3. Signature of Person Who Prepared This Form N-300 for You (if applicable) I declare under the penalty of perjury that I prepared this application at the request of the above person. Preparer’s Printed Name [text box] Preparer’s Signature [text box] Date (mm/dd/yyyy) [text box] Preparer’s Firm or Organization Name (if applicable) [text box] Preparer’s Daytime Phone Number [text box] Preparer’s Address Street Number and Name (do not provide a P.O. Box in this space) *** City [text box] County [text box] State [text box] ZIP Code [text box] Preparer’s E-Mail Address [text box] Preparer’s Fax Number [text box] .
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 Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number ( ) E-Mail Address (If any) 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. *** ____________________ Signature of Applicant _____________________ Signature of Authorizing Official ____________________ Date ____________________ Date	Part 4. Declaration of Intent 1. Current Legal Name (do not provide a nickname) Family Name (last name) [text box] Given Name (first name) [text box] Middle Name (if applicable) [text box] 2. U.S. Social Security Number (if any) [text box] 3. Date of Birth (mm/dd/yyyy) [text box] 4. Country of Birth [text box] 5. Date You Became a Permanent Resident (mm/dd/yyyy) [text box] 6. Country of Nationality [text box] 7. Home Address Street Number Street Name (do not provide a P.O. Box in this space) Apartment Number [text box] City [text box] County [text box] State [text box] ZIP Code [text box] 8. Mailing Address C/O (in care of name) [text box] Street Number and Name [text box] Apartment Number [text box] City [text box] State [text box] ZIP Code [text box] 9. Daytime Phone Number [text box] Work Phone Number (if any) [text box] Evening Phone Number [text box] Mobile Phone Number (if any) [text box] 10. E-Mail Address (if any) [text box] I am over the age of 18 years, have been admitted to the United States as a permanent resident, and am now residing in the United States based on such admission. *** Your Signature (USCIS will reject your Form N-300 if it is not signed.) [text box] Date (mm/dd/yyyy) [text box] USCIS Officer’s Signature [text box] Date (mm/dd/yyyy) [text box]
Page 2, bottom of the page	Original Copy/Retained by USCIS
Page 3	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 Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number ( ) E-Mail Address (If any) 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. *** ____________________ Signature of Applicant _____________________ Signature of Authorizing Official ____________________ Date ____________________ Date
Page 3, bottom of the page	Duplicate Copy/Given to Applicant	Original Mailed to Applicant/Copy to File

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