Page 1
|
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 (three pages)
Part 1. Information About You
1. Current Legal Name (do
not provide a nickname)
Family Name (last name)
Given Name (first name)
Middle Name (if applicable)
2. U.S. Social Security Number
(if any)
3. Date of Birth
(mm/dd/yyyy)
4. Country of Birth
5. Date You Became a Permanent
Resident (mm/dd/yyyy)
6. Country of Nationality
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
8. Mailing Address
C/O (in care of name)
Street Number and Name
Apartment Number
City
State
ZIP Code
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
City
State
ZIP Code
Country
9. Daytime Phone Number
Work Phone Number (if any)
Evening Phone Number
Mobile Phone Number (if
any)
10. E-mail Address (if
any)
|
[Page 1]
Part 1.
Information About You
[Delete]
[Delete]
[No change]
1. Your
Current Legal Name (do not provide a nickname)
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
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) [2 boxes]
Given Name (First Name) [2 boxes]
Middle Name [2 boxes]
3. U.S.
Social Security Number (if any)
4. USCIS
ELIS Account Number (if any)
5.
Date of Birth (mm/dd/yyyy)
6.
Date You Became a Lawful Permanent
Resident (mm/dd/yyyy)
7.
Country of Birth
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 the
departure/arrival dates of all absences in
the space provided in Part 5.
Additional Information.
[Page2]
10.
Mailing Address
In Care Of Name (if
any)
[No change]
Apt. Ste.
Flr. Number
City or Town
[No change]
[No change]
11.
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
[No change]
[No change]
[Delete]
[Delete]
|
Page 2
|
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 in Part 4.
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.
Your Signature
Date (mm/dd/yyyy)
|
[Page 2]
Part 2.
Applicant’s
Statement, Contact
Information, Acknowledgement of Appointment at USCIS Application
Support Center, Certification, and Signature
NOTE:
Read the information on penalties in 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 have read and understand
every question and instruction on this application,
as well as my answer to every question.
I have read and understand the Acknowledgement
of Appointment at USCIS Application
Support Center.
B.
The interpreter named in Part
3.
has also read to me every question and instruction on this
application,
as well as my answer to every question, in
____________________________, a language in which I am fluent. I
understand every question and instruction on this application
as translated to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated above. The
interpreter named in Part 3.
has also read the Acknowledgement
of Appointment at USCIS Application
Support Center to
me, in the language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement as read to me by
my interpreter.
2.
Applicant’s Statement Regarding the Preparer
I have
requested the services of and consented to
____________________________, who is/is not an attorney or
accredited representative, preparing this application
for me. This person who assisted me in preparing my application
has reviewed the Acknowledgement
of Appointment at USCIS Application
Support Center with me, and I
understand the ASC Acknowledgement.
Applicant’s
Contact Information
3.
Applicant’s Daytime
Telephone Number
4.
Applicant’s Mobile Telephone
Number (if any)
5.
Applicant’s Email Address (if
any)
Acknowledgement
of Appointment at USCIS Application
Support Center
I,
___________________________________, understand
that the purpose of a U.S. Citizenship and Immigration Services
(USCIS) ASC appointment is for me to provide my fingerprints,
photograph, and/or signature and to re-affirm that all of the
information in my application
is complete, true, and correct and was provided by me. I
understand that I will sign my name to the following declaration
which USCIS will display to me at the time I provide my
fingerprints, photograph, and/or signature during my ASC
appointment.
By
signing here, I declare under penalty of perjury that I have
reviewed and understand my application, petition, or request as
identified by the receipt number displayed on the screen above,
and all supporting documents, applications, petitions, or requests
filed with my application, petition, or request that I (or my
attorney or accredited representative) filed with USCIS, and that
all of the information in these materials is complete, true, and
correct.
I also
understand that when I sign my name, provide my fingerprints, and
am photographed at the USCIS ASC, I will be re-affirming that I
willingly submit this application;
I have reviewed the contents of this application;
all of the information in my application
and all supporting documents submitted with my application
were provided by me and are complete,
true, and correct; and if I was assisted in completing this
application,
the person assisting me also reviewed this Acknowledgement
of Appointment at USCIS Application Support Center
with me.
[Page 3]
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 and all of my
records that USCIS may need to determine my eligibility for the
immigration benefit that I seek.
I furthermore
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 certify,
under penalty of perjury, that the
information in my application, my
responses to each question, and any
document submitted with my application
were provided by me and are 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.
|
NEW
|
|
[Page 3]
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.
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Interpreter’s
Contact Information
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Email Address (if any)
[Page 4]
Interpreter’s
Certification
I
certify that:
I
am fluent in English and ________________,
which
is the same language provided in Part
2.,
Item
B.
in Item
Number 1.;
I
have read to this applicant every question and instruction on this
application,
as well as the answer to every question, in the language provided
in Part
2.,
Item
B.
in Item
Number 1.;
and
I
have read the Acknowledgement
of Appointment at USCIS Application Support Center
to the applicant in the same language provided in Part
2.,
Item
B. in
Item Number 1.
The
applicant has informed me that he or she understands every
instruction and question on the application,
as well as the answer to every question, and the applicant
verified
the accuracy of every answer;
and
The
applicant has also informed me that he or she understands the ASC
Acknowledgement and that by appearing for a USCIS ASC biometric
services appointment and providing his or her fingerprints,
photograph, and/or signature, he or she is re-affirming that the
contents of this application
and all supporting documentation are complete, true, and correct.
Interpreter’s
Signature
6.
Interpreter’s
Signature
Date of
Signature (mm/dd/yyyy)
|
|
Part 3. Signature of Person Who
Prepared This Form for You (if applicable)
Preparer’s Firm or
Organization Name (if applicable)
Preparer’s Address
Street Number and Name
City
Country
State
ZIP Code
Preparer’s Daytime Phone
Number
Preparer’s Fax Number
Preparer’s E-mail Address (if
any)
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)
|
[Page
4]
Part
4.
Contact Information, Statement, Certification, and Signature of
the Person Preparing 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.
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Preparer’s
Contact Information
4.
Preparer’s
Daytime Telephone Number
5.
Preparer’s
Fax Number
6.
Preparer’s
Email
Address
(if any)
[Page
5]
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
must 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, swear, or affirm, under
penalty of perjury,
that
I prepared this application
on behalf of, at the
request of,
and with the express consent of the applicant. I completed this
application
based
only
on
responses
the applicant provided to me. After completing the application, I
reviewed it and all of the applicant’s responses with the
applicant, who agreed with every answer on the application. If
the applicant supplied additional information concerning a
question on the application, I recorded it on the application. I
have also read the Acknowledgement
of Appointment at USCIS Application Support Center
to the applicant and the applicant has informed me that he or she
understands the ASC Acknowledgement.
Preparer’s
Signature
[Delete]
8.
Preparer’s Signature
Date of
Signature (mm/dd/yyyy)
|
Page 3
|
Part 4. Declaration of Intent
1. Current Legal Name (do
not provide a nickname)
Family Name (last name)
Given Name (first name)
Middle Name (if applicable)
2. U.S. Social Security Number
(if any)
3. Date of Birth
(mm/dd/yyyy)
5. Date You Became a Permanent
Resident (mm/dd/yyyy)
4. Country of Birth
6. Country of Nationality
8. Mailing Address
C/O (in care of name)
Street Number and Name
City
State
ZIP Code
7. Home Address
Street Number and Name (do not
provide a P.O. Box in this space)
Apartment Number
City
Country
State
ZIP Code
9. Daytime Phone Number
Work Phone Number (if any)
Evening Phone Number
Mobile Phone Number (if
any)
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 photograph 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)
|
[Page 7]
[This section
autofills from data already collected in the form, unless an
applicant completes Form N-300 by hand.]
Part 6.
Declaration of Intent
1. Your
Current Legal Name (do not provide a nickname)
Family Name (Last Name)
Given Name (First Name)
Middle Name
2. U.S. Social Security
Number (if any)
3.
USCIS ELIS Account Number (if any)
4.
Date of Birth (mm/dd/yyyy)
5.
Date You Became a Lawful Permanent
Resident (mm/dd/yyyy)
6.
Country of Birth
7.
Country of Citizenship or Nationality
8. Mailing Address
In Care Of
Name (if any)
Street Number and Name
Apt. Ste.
Flr. Number
City
State
ZIP Code
9.
Physical Address
Street Number and Name (Do not
provide a PO Box in this space)
Apt. Ste.
Flr. Number
City or Town
[Delete]
State
ZIP Code
10.
Daytime Telephone Number
11.
Work Telephone Number (if any)
12.
Evening Telephone Number
13.
Mobile Telephone Number (if
any)
14. Email
Address (if any)
[Page
8]
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 photograph 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.
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 Photo Here]
|