Form N-300 - Application To File, Declaration Of Intention

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OMB No. 1615-0078; Expires 03/31/2016
Form N-300, Application to File
Department of Homeland Security
Declaration of Intention
U. S. Citizenship and Immigration Services
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 (four pages).
Your A-Number:
Part 1. Information About You
-
-
A
1. Current Legal Name (do not provide a nickname)
Family Name (last name)
For USCIS Use Only
Bar Code
Date Stamp
Given Name (first name)
Middle Name (if applicable)
(if any)
2.
U.S. Social Security Number
3.
Date of Birth (mm/dd/yyyy)
Remarks
4.
Country of Birth
5.
Date You Became a Permanent Resident (mm/dd/yyyy)
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.
6.
Country of Nationality
Action
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
County
State
ZIP Code
8. Mailing Address
C/O (in care of name)
Street Number and Name
Apartment Number
City
State
ZIP Code
Form N-300 (03/21/13) N

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