Form N-300 - Application To File, Declaration Of Intention Page 3
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Part 4. Declaration of Intent
A
1. Current Legal Name (do not provide a nickname)
Family Name (last name)
Given Name (first name)
Affix
Middle Name (if applicable)
Photograph
2.
U.S. Social Security Number
3.
Date of Birth (mm/dd/yyyy)
(if any)
Here
4.
Country of Birth
5. Date You Became a Permanent Resident (mm/dd/yyyy)
Not valid unless DHS Seal
applied below.
6.
Country of Nationality
7. Home Address
Street Number and Name (do not provide a P.O. Box in this space)
Apartment Number
ZIP Code
City
County
State
8. Mailing Address
C/O (in care of name)
Apartment Number
Street Number and Name
City
State
ZIP Code
9. Daytime Phone Number
Work Phone Number (if any)
Evening Phone Number
(
)
(
)
(
)
10.
E-Mail Address (if any)
Mobile Phone Number (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 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.
Date (mm/dd/yyyy)
Your Signature (USCIS will reject your Form N-300 if it is not signed)
Date (mm/dd/yyyy)
USCIS Officer's Signature
Form N-300 (03/21/13) N Page 3
Original Mailed to Applicant/Copy to File
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Parent category: Legal