Form N-300 Application to File Declaration of Intention

Application to File Declaration of Intention

USCIS
Form N-300

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

OMB No. 1615-0078
Expires 03/31/2016

For USCIS Use Only
Date Stamp

Receipt

DRAFT
NOT FOR
PRODUCTION
02/24/2016

Remarks

To be completed by an
attorney or accredited
representative (if any).

Bar Code

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

► START HERE - Type or print in black ink.

► A-

Your Current Legal Name (do not provide a nickname)
Family Name (Last Name)

2.

Attorney or Accredited Representative
USCIS Online Account Number (if any)

Enter Your 9 Digit A-Number:

Part 1. Information About You
1.

Action Block

Given Name (First Name)

Middle Name

Other Names Used (if any)

List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this
section, use the space provided in Part 5. Additional Information.
Family Name (Last Name)

3.

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

6.

Given Name (First Name)

4.

USCIS Online Account Number (if any)

Middle Name

5.

Date of Birth (mm/dd/yyyy)

►

Date You Became a Lawful Permanent Resident

7.

Country of Birth

(mm/dd/yyyy)
8.

Country of Citizenship or Nationality

9.

Since you were admitted to the United States as a lawful permanent resident, have you been absent for a
period of six months or longer?

Yes

No

If you answered "Yes" to Item Number 9., provide departure/arrival dates of all absences in the space provided in Part 5.
Additional Information.

Form N-300 03/21/13 N

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Part 1. Information About You (continued)
10. Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

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City or Town

State

ZIP Code

11. Physical Address

Street Number and Name (do not provide a PO Box in this space unless it is your ONLY address)

City or Town

Apt. Ste. Flr. Number

State

ZIP Code

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form N-300 Instructions before completing this part. You must file Form N-300 while in
the United States.

Applicant's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Applicant's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this application and
my answer to every question.

B.

The interpreter named in Part 3. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am
fluent and I understood everything.

2.

Applicant's Statement Regarding the Preparer
At my request, the preparer named in Part 4.,
prepared this application for me based only upon information I provided or authorized.

,

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

Form N-300 03/21/13 N

4.

Applicant's Mobile Telephone Number (if any)

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► A-

Part 2. Applicant's Statement, Contact Information, Certification, and
Signature (continued)
Applicant's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

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NOT FOR
PRODUCTION
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I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my application;

2) I understood all of the information contained in, and submitted with, my application; and
3) All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.

Applicant's Signature
6.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.

Part 3. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form N-300 03/21/13 N

Postal Code

ZIP Code

Country

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► A-

Part 3. Interpreter's Contact Information, Certification, and Signature
(continued)
Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

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Interpreter's Certification

I certify, under penalty of perjury, that:

, which is the same language provided in Part 2.,
I am fluent in English and
Item B., in Item Number 1.; and I have read to this applicant in the identified language every question and instruction on this
application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question,
and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 4. Contact Information, Declaration, and Signature of the Person Who Prepared This Application,
if Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form N-300 03/21/13 N

Postal Code

ZIP Code

Country

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Part 4. Contact Information, Statement, Certification, and Signature of
the Person Who Prepared This Application, if Other Than the Applicant
(continued)

► A-

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

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Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case
extends
does not extend beyond the preparation of this application.
NOTE: If you are an attorney or accredited representative whose representation extends
beyond preparation of this application, you may be obliged to submit a completed Form G-28,
Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

Form N-300 03/21/13 N

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Part 5. Additional Information

If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item
Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A. Page Number

D.

3.

4.

A. Page Number

D.

5.

Middle Name

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A. Page Number

D.

Given Name (First Name)

A. Page Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

Form N-300 03/21/13 N

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Part 6. Declaration of Intent
1.

Your Current Legal Name (do not provide a nickname)
Family Name (Last Name)

2.

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

4.

Given Name (First Name)

3.

Middle Name

USCIS Online Account Number (if any)
►

DRAFT
NOT FOR
PRODUCTION
02/24/2016

Date of Birth (mm/dd/yyyy)

5.

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

6.

Country of Birth

8.

Mailing Address

7.

Country of Citizenship or Nationality

In Care Of Name (if any)

9.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Physical Address

Street Number and Name (do not provide a PO Box in this space unless it is your ONLY address)

Apt. Ste. Flr. Number

City or Town

State

10. Daytime Telephone Number

11. Work Telephone Number (if any)

12. Evening Telephone Number

13. Mobile Telephone Number (if any)

ZIP Code

14. Email Address (if any)

Form N-300 03/21/13 N

Original Mailed to Applicant/Copy to File

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Part 6. Declaration of Intent (continued)

I am over 18 years of age, have been lawfully admitted to the United States as a lawful 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.

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Applicant's and USCIS Officer's Signature

15. Applicant's Signature (USCIS will reject your Form N-300 if it is not signed)

Date of Signature (mm/dd/yyyy)

16. USCIS Officer's Signature

Date of Signature (mm/dd/yyyy)

Affix

Photograph
Here

Not valid unless DHS Seal
applied below.

Form N-300 03/21/13 N

Original Mailed to Applicant/Copy to File

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