Download:
pdf |
pdfApplication For Naturalization
USCIS
Form N-400
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
Date Stamp
Receipt
OMB No. 1615-0052
Expires 03/31/2013
Action Block
Remarks
Type or print all your answers in black ink. Type or print "N/A" if an item is not applicable or the answer is "none" unless
otherwise indicated. Failure to answer all of the questions may delay USCIS processing your Form N-400. NOTE: You must
complete Parts 1. - 14.
Draft
Not for
Production
06/28/2013
Part 1. Information About Your Eligibility (Check only one box or your
Form N-400 may be delayed)
Enter Your 9 Digit A-Number:
► A-
You are at least 18 years old and
1.
Have been a Permanent Resident of the United States for at least 5 years.
2.
Have been a Permanent Resident of the United States for at least 3 years. In addition, you have been married to and living
with the same U.S. citizen spouse for the last 3 years, and your spouse has been a U.S. citizen for the last 3 years at the time
of filing your Form N-400.
3.
Are a Permanent Resident of the United States, and you are the spouse of a U.S. citizen, and your U.S. citizen spouse is
regularly engaged in specified employment abroad. (Section 319(b) of the Immigration and Nationality Act)
4.
Are applying on the basis of qualifying military service.
5.
Other (explain):
Part 2. Information About You (Person applying for naturalization)
1.
Your Current Legal Name (do not provide a nickname)
Family Name (Last Name)
2.
Middle Name (if applicable)
Your Name Exactly As It Appears on Your Permanent Resident Card (if applicable)
Family Name (Last Name)
3.
Given Name (First Name)
Given Name (First Name)
Middle Name (if applicable)
Other Name(s) You Have Used Since Birth (include nicknames, aliases, and maiden name if applicable)
Family Name (Last Name)
Form N-400 06/28/13 N
Given Name (First Name)
Middle Name (if applicable)
Page 1 of 21
A-
Part 2. Information About You (continued)
4.
Name Change (optional)
Read the Form N-400 Instructions before you decide whether or not you would like to legally change your name.
Would you like to legally change your name?
Yes
If ''Yes," print the new name you would like to use in the space below.
Family Name (Last Name)
Given Name (First Name)
5.
U.S. Social Security Number
(if applicable)
6.
7.
Date of Birth
(mm/dd/yyyy)
►
No
Middle Name (if applicable)
Date You Became a Permanent Resident
(mm/dd/yyyy)
Draft
Not for
Production
06/28/2013
►
9.
Country of Citizenship or Nationality
8.
Country of Birth
10.
Are you requesting an accommodation(s) to the naturalization process because of a disability and/or
an impairment? (See Form N-400 Instructions for accommodation examples)
Yes
No
If "Yes," check the box(es) below that applies:
Deaf or hard of hearing and need an interpreter who uses the following sign language (e.g., American Sign Language):
Use a wheelchair or other device that assists with mobility.
Blind or low vision.
Require another type of accommodation. (explain):
11.
Do you have a physical or developmental disability or mental impairment that prevents you from
demonstrating your knowledge and understanding of the English language and/or civics requirements
for naturalization?
Yes
No
If "Yes," submit a completed Form N-648, Medical Certification for Disability Exceptions, when you file your Form N-400.
12.
Exemptions from the English Language Test
A. Are you 50 years of age or older and have you lived in the United States as a Permanent Resident for
periods totaling at least 20 years at the time of filing your Form N-400?
Yes
No
B. Are you 55 years of age or older and have you lived in the United States as a Permanent Resident for
periods totaling at least 15 years at the time of filing your Form N-400?
Yes
No
C. Are you 65 years of age or older and have you lived in the United States as a Permanent Resident for
periods totaling at least 20 years at the time of filing your Form N-400? (If you meet this requirement,
you will also be given a simplified version of the civics test.)
Yes
No
Form N-400 06/28/13 N
Page 2 of 21
A-
Part 3. Information to Contact You
1.
4.
Daytime Phone Number
(
)
2.
Work Phone Number (if any)
(
-
Mobile Phone Number (if any)
(
)
5.
)
3.
-
Evening Phone Number
(
)
-
E-mail Address (if any)
Part 4. Information About Your Residence
1.
Where have you lived during the last 5 years? Begin with where you live now and then list every location where you have
lived during the last 5 years. If you need more space, use an additional sheet(s) of paper.
Date of Residence
Draft
Not for
Production
06/28/2013
From (mm/dd/yyyy) ►
To (mm/dd/yyyy) ► Present
Street Number and Name
City
Province or Region (foreign address only)
Apt. Ste. Flr. Number
County
State
ZIP Code + 4
-
Country (foreign address only)
Postal Code (foreign address only)
A. Mailing Address (if different from the address above)
C/O ("In Care Of" Name, if applicable)
Street Number and Name
City
Province or Region (foreign address only)
Form N-400 06/28/13 N
Apt. Ste. Flr. Number
State
Country (foreign address only)
ZIP Code + 4
-
Postal Code (foreign address only)
Page 3 of 21
A-
Part 4. Information About Your Residence (continued)
2.
Date of Residence
From (mm/dd/yyyy) ►
To (mm/dd/yyyy) ►
Street Number and Name
3.
Apt. Ste. Flr. Number
City
County
State
Province or Region (foreign address only)
Country (foreign address only)
Postal Code (foreign address only)
Date of Residence
Draft
Not for
Production
06/28/2013
From (mm/dd/yyyy) ►
To (mm/dd/yyyy) ►
Street Number and Name
City
Date of Residence
Apt. Ste. Flr. Number
County
Province or Region (foreign address only)
4.
State
Country (foreign address only)
From (mm/dd/yyyy) ►
Province or Region (foreign address only)
Form N-400 06/28/13 N
ZIP Code + 4
-
Postal Code (foreign address only)
To (mm/dd/yyyy) ►
Street Number and Name
City
ZIP Code + 4
-
Apt. Ste. Flr. Number
County
State
ZIP Code + 4
-
Country (foreign address only)
Postal Code (foreign address only)
Page 4 of 21
A-
Part 5. Information About Your Parents
If your biological or legally adoptive mother or father is a U.S. citizen by birth, or naturalized before you reached your 18th
birthday, you may already be a U.S. citizen. Visit the USCIS Web site at www.uscis.gov for further information on this topic
before you consider filing Form N-400.
1.
Were your parents married before your 18th birthday?
Yes
No
2.
Is your mother a U.S. citizen?
If "Yes," complete the following information.
Yes
No
A. Current Legal Name of U.S. Citizen Mother
Mother's Family Name (Last Name)
Mother's Given Name (First Name)
Draft
Not for
Production
06/28/2013
C. Mother's Date of Birth (mm/dd/yyyy)
►
B. Mother's Country of Birth
3.
Mother's Middle Name (if applicable)
Is your father a U.S. citizen?
Yes
No
If ''Yes," complete the information below.
A. Current Legal Name of U.S. Citizen Father
Father's Family Name (Last Name)
Father's Given Name (First Name)
Father's Middle Name (if applicable)
C. Father's Date of Birth (mm/dd/yyyy)
B. Father's Country of Birth
►
Part 6. Information for Criminal Records Check
NOTE: USCIS requires you to complete the categories below to conduct background checks. (See Form N-400 Instructions for more
information)
1.
Gender
3.
Ethnicity (Select one)
Male
Female
Hispanic or Latino
4.
Height Feet
Inches
Not Hispanic or Latino
Race (Select one or more)
White
5.
2.
Asian
Black or
African American
Native Hawaiian or
Other Pacific Islander
American Indian
or Alaska Native
Hair color
Black
Form N-400 06/28/13 N
Brown
Blonde
Gray
White
Red
Sandy
Bald (No hair)
Page 5 of 21
A-
Part 6. Information for Criminal Records Check (continued)
6.
Eye color
Brown
Blue
Green
Hazel
Gray
Black
Pink
Maroon
Other
Part 7. Information About Your Employment and Schools You Attended
List where you have worked or attended school full time or part time during the last 5 years. Provide information for the
complete time period. Include all military, police, and/or intelligence service. Begin by providing information about your most
recent or current employment, studies, or unemployment (if applicable). Provide the locations and dates where you worked, were
self-employed, were unemployed, or have studied for the last 5 years. If you worked for yourself, write "self-employed." If you were
unemployed, write "unemployed." If you need more space, use an additional sheet(s) of paper to complete Part 7.
1.
Draft
Not for
Production
06/28/2013
Employer or School Name
Street Number and Name
City
Apt. Ste. Flr. Number
State
Province or Region (foreign address only)
2.
Country (foreign address only)
Date From (mm/dd/yyyy)
Date To (mm/dd/yyyy)
►
►
ZIP Code + 4
-
Postal Code (foreign address only)
Your Occupation
Employer or School Name
Street Number and Name
City
Apt. Ste. Flr. Number
State
Province or Region (foreign address only)
Date From (mm/dd/yyyy)
►
Form N-400 06/28/13 N
Country (foreign address only)
Date To (mm/dd/yyyy)
►
ZIP Code + 4
-
Postal Code (foreign address only)
Your Occupation
Page 6 of 21
Part 7. Information About Your Employment and Schools You Attended
(continued)
3.
A-
Employer or School Name
Street Number and Name
Apt. Ste. Flr. Number
City
State
ZIP Code + 4
-
Province or Region (foreign address only)
Country (foreign address only)
Postal Code (foreign address only)
Draft
Not for
Production
06/28/2013
Date From (mm/dd/yyyy)
►
Date To (mm/dd/yyyy)
►
Your Occupation
Part 8. Time Outside the United States
1.
How many total days (24 hours or longer) did you spend outside the United States during the last 5 years?
days
2.
How many trips of 24 hours or longer have you taken outside the United States during the last 5 years?
trips
3.
List below all the trips of 24 hours or longer that you have taken outside the United States during the last 5 years.
Begin with your most recent trip and work backwards. If you need more space, use an additional sheet(s) of paper.
Date You Left the
United States
(mm/dd/yyyy)
Form N-400 06/28/13 N
Date You Returned Did Trip Last 6
to the United States Months or More?
(mm/dd/yyyy)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Countries to
Which You Traveled
Total Days
Outside the
United States
Page 7 of 21
A-
Part 9. Information About Your Marital History
1.
What is your current marital status?
Single, never married
Married
Separated
Divorced
Widowed
Marriage annulled
2.
If you are married, is your spouse a current member of the U.S. Armed Forces?
3.
How many times have you been married (including annulled marriages and marriage(s) to the same person)?
Yes
No
If you are single and have never been married, indicate "0" and go to Part 10.
4.
If you are married now, provide the following information about your current spouse.
A. Legal Name of Current Spouse
Draft
Not for
Production
06/28/2013
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Given Name (First Name)
Middle Name (if applicable)
B. Previous Legal Name of Current Spouse
Family Name (Last Name)
C. Other Names Used by Current Spouse (include nicknames, aliases, and maiden name, if applicable)
Family Name (Last Name)
Given Name (First Name)
D. Current Spouse's Date of Birth
(mm/dd/yyyy) ►
Middle Name (if applicable)
E. Date You Entered into Marriage with Current Spouse
(mm/dd/yyyy) ►
F. Current Spouse's Present Home Address
Street Number and Name
City
Province or Region (foreign address only)
Apt. Ste. Flr. Number
County
State
ZIP Code + 4
-
Country (foreign address only)
Postal Code (foreign address only)
G. Current Spouse's Present Employer
5.
Is your current spouse a U.S. citizen?
Yes
No
If ''Yes," answer Item Number 6.
If ''No," go to Item Number 7.
Form N-400 06/28/13 N
Page 8 of 21
A-
Part 9. Information About Your Marital History (continued)
6.
If your current spouse is a U.S. citizen, complete the following information.
A. When did your current spouse become a U.S. citizen?
At birth - Go to Item Number 8.
Other - Complete the following information.
B. Date your current spouse became a U.S. citizen
(mm/dd/yyyy) ►
7.
If your current spouse is not a U.S. citizen, complete the following information.
A. Current Spouse's Country of Citizenship or Nationality
B. Current Spouse's A-Number (if applicable)
► A-
Draft
Not for
Production
06/28/2013
C. Current Spouse's Immigration Status
Permanent Resident
Other (explain):
8.
How many times has your current spouse been married (including annulled marriages and marriage(s)
to the same person)? If your current spouse has been married before, provide the following information about
your current spouse's prior spouse.
If your current spouse has had more than one previous marriage, use an additional sheet(s) of paper to provide the
information requested in Items A. - H. below for each marriage.
A. Prior Spouse's Family Name (Last Name)
B. Prior Spouse's Immigration Status
U.S. Citizen
Permanent Resident
Given Name (First Name)
Middle Name (if applicable)
Other (explain):
C. Prior Spouse's Date of Birth
(mm/dd/yyyy) ►
D. Prior Spouse's Country of Birth
E. Prior Spouse's Country of Citizenship or Nationality
F. Date of Marriage with Prior Spouse
(mm/dd/yyyy) ►
G. Date Marriage Ended with Prior Spouse
(mm/dd/yyyy) ►
H. How Marriage Ended with Prior Spouse
Annulled
Form N-400 06/28/13 N
Divorced
Spouse Deceased
Other (explain):
Page 9 of 21
Part 9. Information About Your Marital History (continued)
9.
A-
If you were married before, provide the following information about your prior spouse. If you have more than one previous
marriage, use an additional sheet(s) of paper to provide the information requested in Items A. - H. below for each
marriage.
A. Your Prior Spouse's Family Name (Last Name) Given Name (First Name)
Middle Name (if applicable)
B. Your Prior Spouse's Immigration Status When Your Marriage Ended
U.S. Citizen
Permanent Resident
Other (explain):
C. Your Prior Spouse's Date of Birth
(mm/dd/yyyy) ►
D. Your Prior Spouse's Country of Birth
Draft
Not for
Production
06/28/2013
E. Your Prior Spouse's Country of Citizenship or Nationality
F. Date of Marriage with Your Prior Spouse
(mm/dd/yyyy) ►
G. Date Marriage Ended with Your Prior Spouse
(mm/dd/yyyy) ►
H. How Marriage Ended with Your Prior Spouse
Annulled
Divorced
Spouse Deceased
Other (explain):
Part 10. Information About Your Children
1.
Indicate your total number of children. (All children should be indicated, including: A. Children who are alive,
missing, deceased; B. Children born in the United States or in other countries; C. Children under 18 years of age
or older; D. Children who are currently married or unmarried; E. Children living with you or elsewhere;
F. Current stepchildren; G. Legally adopted children; and H. Children born when you were not married.)
2.
Provide the following information about all your children (sons and daughters) listed in Item Number 1., regardless of age.
Use an additional sheet(s) of paper to list any additional children.
A.1. Child's Current Legal Name
Family Name (Last Name)
Given Name (First Name)
A.2. Child's A-Number (if applicable)
► A-
A.3. Child's Date of Birth
(mm/dd/yyyy) ►
Middle Name (if applicable)
A.4. Child's Country of Birth
Form N-400 06/28/13 N
Page 10 of 21
Part 10. Information About Your Children (continued)
A-
A.5. Child's Current Address
Apt. Ste. Flr. Number
Street Number and Name
City
County
State
ZIP Code + 4
-
Province or Region (foreign address only)
Country (foreign address only)
Postal Code (foreign address only)
A.6. What is your child's relationship to you? (e.g., biological child, stepchild,
legally adopted child)
Draft
Not for
Production
06/28/2013
B.1. Child's Current Legal Name
Family Name (Last Name)
Given Name (First Name)
B.2. Child's A-Number (if applicable)
► A-
B.3. Child's Date of Birth
(mm/dd/yyyy) ►
Middle Name (if applicable)
B.4. Child's Country of Birth
B.5. Child's Current Address
Apt. Ste. Flr. Number
Street Number and Name
City
Province or Region (foreign address only)
County
State
ZIP Code + 4
-
Country (foreign address only)
Postal Code (foreign address only)
B.6. What is your child's relationship to you? (e.g., biological child, stepchild,
legally adopted child)
Form N-400 06/28/13 N
Page 11 of 21
Part 10. Information About Your Children (continued)
C.1. Child's Current Legal Name
Family Name (Last Name)
C.2. Child's A-Number (if applicable)
► A-
A-
Given Name (First Name)
Middle Name (if applicable)
C.3. Child's Date of Birth
(mm/dd/yyyy) ►
C.4. Child's Country of Birth
C.5. Child's Current Address
Draft
Not for
Production
06/28/2013
Apt. Ste. Flr. Number
Street Number and Name
City
Province or Region (foreign address only)
County
Country (foreign address only)
State
ZIP Code + 4
-
Postal Code (foreign address only)
C.6. What is your child's relationship to you? (e.g., biological child, stepchild,
legally adopted child)
D.1.Child's Current Legal Name
Family Name (Last Name)
Given Name (First Name)
D.2. Child's A-Number (if applicable)
► A-
D.3. Child's Date of Birth
(mm/dd/yyyy) ►
Middle Name (if applicable)
D.4. Child's Country of Birth
D.5.Child's Current Address
Apt. Ste. Flr. Number
Street Number and Name
City
Province or Region (foreign address only)
County
State
ZIP Code + 4
-
Country (foreign address only)
Postal Code (foreign address only)
D.6. What is your child's relationship to you? (e.g., biological child, stepchild,
legally adopted child)
Form N-400 06/28/13 N
Page 12 of 21
A-
Part 11. Additional Information
Answer Item Numbers 1. - 21. If you answer "Yes" to any of these questions, include a written explanation on an additional
sheet(s) of paper and provide any evidence to support your answer.
1.
Have you ever claimed to be a U.S. citizen (in writing or any other way)?
Yes
No
2.
Have you ever registered to vote in any Federal, State, or local election in the United States?
Yes
No
3.
Have you ever voted in any Federal, State, or local election in the United States?
Yes
No
4.
Do you now have, or did you ever have, a hereditary title or an order of nobility in any foreign country?
Yes
No
5.
Have you ever been declared legally incompetent, or been confined to a mental institution?
No
6.
Do you owe any overdue Federal, State, or local taxes?
Yes
No
7.
A. Have you ever not filed a Federal, State, or local tax return since you became a Permanent Resident?
Yes
No
B. If "Yes," did you consider yourself to be a "non-U.S. resident"?
Yes
No
8.
Have you called yourself a "non-U.S. resident" on a Federal, State, or local tax return since you became a
Permanent Resident?
Yes
No
9.
Draft
Not for
Production
06/28/2013
Yes
A. Have you ever been a member of, involved in, or in any way associated with, any organization,
association, fund, foundation, party, club, society, or similar group in the United States or in any other
location in the world?
Yes
No
B. If "Yes," provide the information below. If you need more space, attach the names of the other group(s) on an
additional sheet(s) of paper and provide any evidence to support your answer.
Name of Group
10.
Purpose of the Group
Dates of Membership
From
To
(mm/dd/yyyy) (mm/dd/yyyy)
Have you ever been a member of, or in any way associated (either directly or indirectly) with:
A. The Communist Party?
Yes
No
B. Any other totalitarian party?
Yes
No
C. A terrorist organization?
Yes
No
Form N-400 06/28/13 N
Page 13 of 21
Part 11. Additional Information (continued)
A-
11.
Have you ever advocated (either directly or indirectly) the overthrow of any government by force or
violence?
Yes
No
12.
Have you ever persecuted (either directly or indirectly) any person because of race, religion, national
origin, membership in a particular social group, or political opinion?
Yes
No
13.
Between March 23, 1933 and May 8, 1945, did you work for or associate in any way (either directly or
indirectly) with:
A. The Nazi government of Germany?
Yes
No
B. Any government in any area (1) occupied by, (2) allied with, or (3) established with the help of the
Nazi government of Germany?
Yes
No
C. Any German, Nazi, or S.S. military unit, paramilitary unit, self-defense unit, vigilante unit, citizen unit,
police unit, government agency or office, extermination camp, concentration camp, prisoner of war
camp, prison, labor camp, or transit camp?
Yes
No
Were you ever involved in any way with any of the following:
A. Genocide?
Yes
No
B. Torture?
Yes
No
C. Killing, or trying to kill, someone?
Yes
No
D. Badly hurting, or trying to hurt, a person on purpose?
Yes
No
E. Forcing, or trying to force, someone to have any kind of sexual contact or relations?
Yes
No
F. Not letting someone practice his or her religion?
Yes
No
Yes
No
B. Paramilitary unit? (a group of people who act like a military group but are not part of the official
military)
Yes
No
C. Police unit?
Yes
No
D. Self-defense unit?
Yes
No
E. Vigilante unit? (a group of people who act like the police, but are not part of the official police)
Yes
No
F. Rebel group?
Yes
No
G. Guerrilla group? (a group of people who use weapons against or otherwise physically attack the
military, police, government, or other people)
Yes
No
H. Militia? (an army of people, not part of the official military)
Yes
No
I.
Yes
No
14.
15.
Draft
Not for
Production
06/28/2013
Were you ever a member of, or did you ever serve in, help, or otherwise participate in, any of the
following groups:
A. Military unit?
Insurgent organization? (a group that uses weapons and fights against a government)
Form N-400 06/28/13 N
Page 14 of 21
Part 11. Additional Information (continued)
16.
A-
Were you ever a worker, volunteer, or soldier, or did you otherwise ever serve in any of the following:
A. Prison or jail?
Yes
No
B. Prison camp?
Yes
No
C. Detention facility? (a place where people are forced to stay)
Yes
No
D. Labor camp? (a place where people are forced to work)
Yes
No
E. Any other place where people were forced to stay?
Yes
No
Were you ever a part of any group, or did you ever help any group, unit, or organization that used a
weapon against any person, or threatened to do so?
Yes
No
A. If "Yes," when you were part of this group, or when you helped this group, did you ever use a weapon
against another person?
Yes
No
B. If "Yes," when you were part of this group, or when you helped this group, did you ever tell another
person that you would use a weapon against that person?
Yes
No
Did you ever sell, give, or provide weapons to any person, or help another person sell, give, or provide
weapons to any person?
A. If "Yes," did you know that this person was going to use the weapons against another person?
Yes
No
Yes
No
B. If "Yes," did you know that this person was going to sell or give the weapons to someone who was
going to use them against another person?
Yes
No
19.
Did you ever receive any type of military, paramilitary (a group of people who act like a military group but
are not part of the official military), or weapons training?
Yes
No
20.
Did you ever recruit (ask), enlist (sign up), conscript (require), or use any person under age 15 to serve in
or help an armed force or group?
Yes
No
21.
Did you ever use any person under age 15 to do anything that helped or supported people in combat?
Yes
No
17.
18.
Draft
Not for
Production
06/28/2013
If any of Item Numbers 22. - 28. apply to you, you must answer "Yes" even if your records have been sealed, expunged, or
otherwise cleared. You must disclose this information even if anyone, including a judge, law enforcement officer, or attorney, told
you that it no longer constitutes a record or told you that you do not have to disclose the information.
22.
Have you ever committed, assisted in committing, or attempted to commit, a crime or offense for which you
were not arrested?
Yes
No
23.
Have you ever been arrested, cited, or detained by any law enforcement officer (including any and all
immigration officials or the U.S. Armed Forces) for any reason?
Yes
No
24.
Have you ever been charged with committing, attempting to commit, or assisting in committing a crime or
offense?
Yes
No
25.
Have you ever been convicted of a crime or offense?
Yes
No
26.
Have you ever been placed in an alternative sentencing or a rehabilitative program (e.g., diversion,
deferred prosecution, withheld adjudication, deferred adjudication)?
Yes
No
Form N-400 06/28/13 N
Page 15 of 21
A-
Part 11. Additional Information (continued)
27.
28.
A. Have you ever received a suspended sentence, been placed on probation, or been paroled?
Yes
No
B. If "Yes," have you completed the probation or parole?
Yes
No
A. Have you ever been in jail or prison?
Yes
No
B. If "Yes," how long were you in jail or prison?
29.
Years
Months
Days
If you answered "Yes" to Item Numbers 23. - 28., complete the following table. If you need more space, use an additional
sheet(s) of paper and provide any evidence to support your answer. If you answered "No" to all Item Numbers 23. - 28.,
go to Item Number 30.
Why were you
arrested, cited,
detained, or charged?
Date arrested, cited, Where were you arrested, cited,
detained, or
detained, or charged?
charged.
(City, State, Country)
(mm/dd/yyyy)
Outcome or disposition of the
arrest, citation, detention or
charge (no charges filed, charges
dismissed, jail, probation, etc.)
Draft
Not for
Production
06/28/2013
Answer Item Numbers 30. - 46. If you answer "Yes" to any of these questions, except Item Numbers 37. and 38., include a
written explanation on an additional sheet(s) of paper and provide any evidence to support your answer.
30.
Have you ever:
A. Been a habitual drunkard?
Yes
No
B. Been a prostitute, or procured anyone for prostitution?
Yes
No
C. Sold or smuggled controlled substances, illegal drugs, or narcotics?
Yes
No
D. Been married to more than one person at the same time?
Yes
No
E. Married someone in order to obtain an immigration benefit?
Yes
No
F. Helped anyone to enter, or try to enter, the United States illegally?
Yes
No
G. Gambled illegally or received income from illegal gambling?
Yes
No
H. Failed to support your dependents or to pay alimony?
Yes
No
I.
Yes
No
Made any misrepresentation to obtain any public benefit in the United States?
Form N-400 06/28/13 N
Page 16 of 21
A-
Part 11. Additional Information (continued)
31.
Have you ever given any U.S. Government official(s) any information or documentation that was false,
fraudulent, or misleading?
Yes
No
32.
Have you ever lied to any U.S. Government official to gain entry or admission into the United States or to
gain immigration benefits while in the United States?
Yes
No
33.
Have you ever been removed, excluded, or deported from the United States?
Yes
No
34.
Have you ever been ordered removed, excluded, or deported from the United States?
Yes
No
35.
Have you ever been placed in removal, exclusion, rescission, or deportation proceedings?
Yes
No
36.
Are removal, exclusion, rescission, or deportation proceedings (including administratively closed
proceedings) currently pending against you?
Yes
No
37.
Have you ever served in the U.S. Armed Forces?
Yes
No
38.
Are you currently a member of the U.S. Armed Forces?
Yes
No
39.
If you are currently a member of the U.S. Armed Forces, are you scheduled to deploy overseas, including
to a vessel, within the next 3 months? (Refer to the Address Change section within the Form N-400
Instructions on how to notify USCIS if you learn of your deployment plans after you file your Form N-400.)
Yes
No
40.
If you are currently a member of the U.S. Armed Forces, are you currently stationed overseas?
Yes
No
41.
Have you ever been court-martialed, administratively separated, or disciplined, or have you received an
other than honorable discharge, while in the U.S. Armed Forces?
Yes
No
42.
Have you ever been discharged from training or service in the U.S. Armed Forces because you were an
alien?
Yes
No
43.
Have you ever left the United States to avoid being drafted in the U.S. Armed Forces?
Yes
No
44.
Have you ever applied for any kind of exemption from military service in the U.S. Armed Forces?
Yes
No
45.
Have you ever deserted from the U.S. Armed Forces?
Yes
No
46.
A. Are you a male who lived in the United States at any time between your 18th and 26th birthdays?
(This does not include living in the United States as a lawful nonimmigrant.)
Yes
No
Draft
Not for
Production
06/28/2013
B. If "Yes," when did you register for the Selective Service? Provide the information below.
Date Registered (mm/dd/yyyy) ►
Form N-400 06/28/13 N
Selective Service Number
Page 17 of 21
Part 11. Additional Information (continued)
A-
C. If "Yes," but you did not register with the Selective Service System and you are:
1.
Still under 26 years of age, you must register before you apply for naturalization, and complete the Selective Service
information above; OR
2.
Now 26 years of age or older but you did not register with the Selective Service, you must attach a statement explaining
why you did not register, and a status information letter from the Selective Service.
Answer Item Numbers 47. - 53. If you answer ''No'' to any of these questions, include a written explanation on an additional
sheet(s) of paper and provide any evidence to support your answer.
47.
Do you support the Constitution and form of government of the United States?
Yes
No
48.
Do you understand the full Oath of Allegiance to the United States?
Yes
No
49.
Are you willing to take the full Oath of Allegiance to the United States?
Yes
No
50.
If the law requires it, are you willing to bear arms on behalf of the United States?
Yes
No
51.
If the law requires it, are you willing to perform noncombatant services in the U.S. Armed Forces?
Yes
No
52.
If the law requires it, are you willing to perform work of national importance under civilian direction?
Yes
No
Yes
No
Draft
Not for
Production
06/28/2013
NOTE: Answer the next question ONLY if you answered "Yes" to Part 11., Item Number 4. of Form N-400.
53.
At your naturalization ceremony, are you willing to give up any inherited title(s) or order(s) of nobility that
you have in a foreign country?
Part 12. Your Signature (USCIS will reject your Form N-400 if it is not signed)
Your Statement
I certify, under penalty of perjury under the laws of the United States of America, that this application, and the evidence submitted
with it, are all true and correct. I authorize the release of any information USCIS needs to determine my eligibility for naturalization.
Your Signature
Date (mm/dd/yyyy)
Part 13. Signature and Contact Information of the Person Who Prepared This Form, If Other Than the
Applicant
By my signature, I certify, swear or affirm, under penalty of perjury, that I prepared this form on behalf of, at the request of, and with
the express consent of the applicant. I completed the form based only on responses the applicant provided to me. After completing
the form, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer he or she provided for
each question on the form and, when required, supplied additional information to respond to a question on the form.
Form N-400 06/28/13 N
Page 18 of 21
A-
Part 13. Signature and Contact Information of the Person Who Prepared
This Form, If Other Than the Applicant (continued)
Preparer's Printed Name
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Preparer's Signature
Date (mm/dd/yyyy)
Preparer's Firm or Organization Name (if applicable)
Preparer's Address
Preparer's Daytime Phone Number
(
)
Draft
Not for
Production
06/28/2013
Street Number and Name
City
Province or Region (foreign address only)
Apt. Ste. Flr. Number
County
Country (foreign address only)
Preparer's E-mail Address
State
ZIP Code + 4
-
Postal Code (foreign address only)
Preparer's Fax Number
(
)
Part 14. Statement of Applicants Who Used an Interpreter
NOTE: If you answered "Yes" to Part 2., Item Numbers 11. or 12. of this form and during the completion of the form used an
interpreter to interpret the questions on the form, then you and your interpreter must complete this section.
Applicant's Statement
Each and every question and instruction on this form, as well as my answer to each question, has been read to me by the interpreter
named below in
, a language in which I am fluent.
(language used)
I understand each and every question and instruction on this form, as translated to me by my interpreter, and have provided true and
correct responses in the language indicated above.
Your Signature
Form N-400 06/28/13 N
Date (mm/dd/yyyy)
Page 19 of 21
Part 14. Statement of Applicants Who Used an Interpreter (continued)
A-
Your Interpreter's Statement
I certify that I am fluent in English and
.
(language used)
I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has informed me that he or she has understood each and every
instruction and question on the form, as well as the answer to each question.
Interpreter's Printed Name
Family Name (Last Name)
Given Name (First Name)
Draft
Not for
Production
06/28/2013
Interpreter's Signature
Telephone Number
(
)
Middle Name (if applicable)
Date (mm/dd/yyyy)
-
NOTE: Do not complete Parts 15., 16., and 17. until the USCIS Officer instructs you to do so at the
interview.
Part 15. Signature at Interview
I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of
this Form N-400, Application for Naturalization, subscribed by me, including corrections number 1 through ____________, are true
and correct. The evidence submitted by me on numbered pages 1 through ________________ is true and correct.
Subscribed to and sworn to (affirmed) before me
USCIS Officer's Printed Name or Stamp
Applicant's Signature
Form N-400 06/28/13 N
Date (mm/dd/yyyy)
USCIS Officer's Signature
Page 20 of 21
Part 16. Renunciation of Foreign Titles
A-
If you answered "Yes" to Part 11., Item Numbers 4. and 53., then you must affirm the following before a USCIS officer:
I further renounce the title of
I further renounce the order of nobility of
which I have heretofore held; or
(list title(s))
(list order of nobility)
to which I have heretofore belonged.
Applicant's Printed Name
Applicant's Signature
USCIS Officer's Printed Name
USCIS Officer's Signature
Draft
Not for
Production
06/28/2013
Part 17. Oath of Allegiance
If your application is approved, you will be scheduled for a public oath ceremony at which time you will be required to take the
following Oath of Allegiance immediately prior to becoming a naturalized citizen. By signing below you acknowledge your
willingness and ability to take this oath:
I hereby declare on oath, that I absolutely and entirely renounce and abjure all allegiance and fidelity to any foreign prince, potentate,
state, or sovereignty, of whom or which I have heretofore been a subject or citizen;
that I will support and defend the Constitution and laws of the United States of America against all enemies, foreign and domestic;
that I will bear true faith and allegiance to the same;
that I will bear arms on behalf of the United States when required by the law;
that I will perform noncombatant service in the Armed Forces of the United States when required by the law;
that I will perform work of national importance under civilian direction when required by the law; and
that I will take this obligation freely, without any mental reservation or purpose of evasion, so help me God.
Applicant's Printed Name
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Applicant's Signature
Form N-400 06/28/13 N
Page 21 of 21
| File Type | application/pdf |
| File Modified | 2013-07-16 |
| File Created | 2013-07-15 |