Form N-300 Application to File Declaration of Intention

OMB No. 1615-0078; Expires 01/31/2012

Form N-300, Application to File
Declaration of Intention

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

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).
Your A-Number:

Part 1. Information About You
1. Current Legal Name (do not provide a nickname)
Family Name (last name)

A

-

-

For USCIS Use Only
Bar Code

Given Name (first name)

Date Stamp

DRAFT
Not
For
Production

Middle Name (if applicable)

2. U.S. Social Security Number (if any)

4. Country of Birth

3. Date of Birth (mm/dd/yyyy)

Remarks

5. 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.

6. Country of Nationality

Action

7. Home Address
Street Number and Name (do not provide a P.O. Box in this space unless it is
your ONLY address.)
Apartment Number
County

City

State

ZIP Code

8. Mailing Address
C/O (in care of name)
Street Number and Name
Apartment Number

City

State

ZIP Code

Form N-300 (Rev. 03/15/13) N

Part 1. Information About You (Continued)
9. Daytime Phone Number

(

)

Work Phone Number (if any)

Evening Phone Number

(

(

)

-

)

10. E-Mail Address (if any)

Mobile Phone Number (if any)

(

-

A

)

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.
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.

DRAFT
NOT
FOR
PRODUCTION

Your Signature

Date (mm/dd/yyyy)

Part 3. Signature of Person Who Prepared This Form for You (if applicable)

I declare under penalty of perjury that I prepared this form at the request of the above person, and it is based on all information of
which I have any knowledge.
Preparer's Printed Name

Preparer's Signature

Date (mm/dd/yyyy)

Preparer's Firm or Organization Name (if applicable)

Preparer's Daytime Phone Number

(

)

Preparer's Address
Street Number and Name

City

Preparer's E-Mail Address (if any)

County

ZIP Code

State

Preparer's Fax Number

(

)

Form N-300 (Rev. 03/15/13) N Page 2

Part 4. Declaration of Intent

-

A

-

1. Current Legal Name (do not provide a nickname)
Family Name (last name)
Given Name (first name)

Affix

Middle Name (if applicable)

Photograph
2. U.S. Social Security Number (if any)

3. Date of Birth (mm/dd/yyyy)

Here
4. Country of Birth

DRAFT
NOT
FOR
PRODUCTION

5. Date You Became a Permanent Resident (mm/dd/yyyy)

Not valid unless DHS Seal
applied below.

6. Country of Nationality

7. Home Address
Street Number and Name (do not provide a P.O. Box in this space)
City

County

Apartment Number
ZIP Code

State

8. Mailing Address
C/O (in care of name)

Apartment Number

Street Number and Name
City

9. Daytime Phone Number

(

)

Mobile Phone Number (if any)

(

ZIP Code

State

Work Phone Number (if any)

Evening Phone Number

(

(

)

)

10. 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 based on such admission.
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.
Your Signature (USCIS will reject your Form N-300 if it is not signed)

Date (mm/dd/yyyy)

USCIS Officer's Signature

Date (mm/dd/yyyy)

Form N-300 (Rev. 03/15/13) N Page 3

Original Mailed to Applicant/Copy to File