Form N-4 Monthly Report on Naturalization Papers

OMB NO. 1615-0051; Expires 11/30/2012

N-4, Monthly Report
on Naturalization Papers

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

Date:

Office of the Clerk of the

Court

(County or District)
(City, State, and Zip Code)

U.S. Citizenship and Immigration Services:
In compliance with the naturalization laws and regulations, listed below are each oath administration ceremony conducted under the

year.

jurisdiction of the above named court during the month and

I have also enclosed the duplicate court list endorsed by me as clerk of the above named court during the same month, except for those
that have already been delivered personnally to your representative. Those so delivered are indicated by an (*) opposite the court list
number.
Also enclosed are (

) voided Certificates of Naturalization. A specific listing of the voided certificates may be found on

each endorsed court list.

(Clerk of Court)
By
Date of
Ceremony

Court List Number

Place of Ceremony

(Deputy Clerk)
Number of Persons
Administered Oath

Number of
Voided Certificates

Form N-4 (Rev. 11/09/09) Y

Instructions
This form is to be submitted monthly by the clerk of any court conducting naturalization activities in conformity with Section 339 of
the Immigration and Nationality Act (8 USC 1450), and Title 8, Code of Federal Regulations, Part 339. The completed form, with a
copy and all attachments, should be submitted to the District Office of U.S. Citizenship and Immigration Services (USCIS) having
jurisdiction over the location of the court.
The USCIS office receiving the form shall retain the duplicate and all attachments, and forward the original to:
U. S. Citizenship and Immigration Services
Headquarters Office of Field Operations
111 Massachusetts Avenue, N.W., 2nd Floor
Washington, D.C. 20529

Authority to Collect Information
Our authority for collecting the information reported on Form N-4 is contained in Section 339 of the Immigration and Nationality
(INA) (8 USC 145D). The information contained in this form will be used by USCIS to finalize the record process regarding persons
naturalized and to determine payments to the courts as provided in Section 344(f) of the INA (8 USC 1455).

Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
30 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Products Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008,
Washington, DC 20529-2210. OMB No. 1615-0051. Do not mail your application to this address.

Form N-4 (Rev. 11/09/09) Y