Application to File Declaration of Intention USCIS

Form N-300
Department of Homeland Security OMB No. 1615-0078
U.S. Citizenship and Immigration Services Expires 03/31/2020

For USCIS Use Only

Date Stamp Receipt Action Block

Remarks Bar Code

To be completed by an Select this box if Attorney State Bar Number Attorney or Accredited Representative
attorney or accredited Form G-28 is (if applicable) USCIS Online Account Number (if any)
representative (if any). attached.

► START HERE - Type or print in black ink.

Enter Your 9 Digit A-Number:
Part 1. Information About You ► A-

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)

Provide 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) Given Name (First Name) Middle Name

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 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 Yes No
period of six months or longer?
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 03/13/18 Page 1 of 8

Part 1. Information About You (continued) ► A-

10. Mailing Address (USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

11. Physical Address (if different from the address above)

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 ZIP Code

Part 2. Applicant's Statement, Contact Information, Declaration, 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 4. Applicant's Mobile Telephone Number (if any)

5. Applicant's Email Address (if any)

Form N-300 03/13/18 Page 2 of 8

Part 2. Applicant's Statement, Contact Information, Declaration, ► A-
Certification, and Signature (continued)
Applicant's Declaration and 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 law.
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 understood all of the information contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury, that all of the information in my application, and any document submitted with it were provided or
authorized by me, that I reviewed and 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 ZIP Code

Province Postal Code Country

Form N-300 03/13/18 Page 3 of 8

Part 3. Interpreter's Contact Information, Certification, and Signature ► A-
(continued)
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 , 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 Declaration and 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 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. Number

City or Town State ZIP Code

Province Postal Code Country

Form N-300 03/13/18 Page 4 of 8

Part 4. Contact Information, Declaration, and Signature of the Person ► A-
Preparing this Application, if Other Than the Applicant (continued)
Preparer's Contact Information
4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any)

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, you may need 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 Declaration and 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 03/13/18 Page 5 of 8

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-Number (if any) ► A-

3. A. Page Number B. Part Number C. Item Number

D.

4. A. Page Number B. Part Number C. Item Number

D.

5. A. Page Number B. Part Number C. Item Number

D.

6. A. Page Number B. Part Number C. Item Number

D.

Form N-300 03/13/18 Page 6 of 8

Part 6. Declaration of Intention ► A-

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

8. Mailing Address
In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

9. 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 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)

Form N-300 03/13/18 Original Mailed to Applicant/Copy to File Page 7 of 8

Part 6. Declaration of Intention (continued) ► A-

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.

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 03/13/18 Original Mailed to Applicant/Copy to File Page 8 of 8