N300-FRM-TOC-OMB-02292016-Highlighted

N300-FRM-TOC-OMB-02292016-Highlighted.docx

Application to File Declaration of Intention

N300-FRM-TOC-OMB-02292016-Highlighted

OMB: 1615-0078

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TABLE OF CHANGES – FORM

Form N-300, Application to File Declaration of Intention

OMB Number: 1615-0078

2/29/2016


Reason for Revision: Incorporate standard language and ELIS data collection


Current Page Number and Section

Current Text

Proposed Text

Page 1, To be completed by an attorney or accredited representative (if any).




[new]

[Page 1]


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


[] Select this box if Form G-28 is attached


Attorney State Bar Number (if applicable)


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


START HERE – Type or print in black ink.


Page 1, Part 1. Information About You






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)


[new]












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




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


[moved up]



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 Online 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


[moved up]



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



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.


[new]





































































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, 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 [Fillable Field], 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., [Fillable Filed], prepared this application for me based only upon information I provided or authorized.

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)


[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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.


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.





[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


[page 4]


Interpreter’s Contact Information


4. Interpreter’s Daytime Telephone Number

5. Interpreter’s Mobile Telephone Number (if any)

6. Interpreter’s Email Address (if any)


Interpreter’s Certification


I certify, under penalty of perjury, that:


I am fluent in English and [Fillable Field], which is the same language provided in Part 2., 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)


Page 2, Part 3. Signature of Person Who Prepared This Form for You (if applicable)




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, Declaration, 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


[page 5]


Preparer’s Contact Information


4. Preparer’s Daytime Telephone Number

5. Preparer’s Mobile Telephone Number

6. Preparer’s Email Address (if any)


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


[Deleted]

8. Preparer’s Signature

Date of Signature (mm/dd/yyyy)





[new]

[Page 6]


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)

Given Name (First Name)

Middle Name


2. A. Page Number

B. Part Number

C. Item Number

D. [Fillable field]


3. A. Page Number

B. Part Number

C. Item Number

D. [Fillable field]



4. A. Page Number

B. Part Number

C. Item Number

D. [Fillable field]



5. A. Page Number

B. Part Number

C. Item Number

D. [Fillable field]


Page 3, Part 4. Declaration of Intent




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


7. Home Address

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

Apartment Number

City

Country

State

ZIP Code


8. Mailing Address

C/O (in care of name)

Street Number and Name


City

State

ZIP Code


[moved down]









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]


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 Online 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


[moved down]









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]




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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleTABLE OF CHANGE – FORM I-687
Authorjdimpera
File Modified0000-00-00
File Created2021-01-24

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