Form N-470 - Application To Preserve Residence For Naturalization Purposes Page 3
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Part 2. Information About You (continued)
A-
Explain your employment position requiring your absence from the United States and the intended length of employment.
14.
15. Have you ever filed an income tax return as a nonresident or otherwise claimed or received benefits as a
Yes
No
nonresident alien under U.S. Federal, state or local income tax laws since you became a lawful
permanent resident?
Part 3. Information About Family Members Who Reside With You
1.
Do you have lawful permanent resident family members who reside with you inside the United States?
Yes
No
2.
If you answered "Yes" to Item Number 1., will those family members reside with you outside the United
Yes
No
States?
If you answered “Yes,” provide the information below for each lawful permanent resident family member who will be residing
with you outside the United States. If you need extra space to complete this section, use the space provided in Part 7. Additional
Information.
A. Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Date of Birth (mm/dd/yyyy)
Relationship to You
A-Number
►
A-
B. Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Date of Birth (mm/dd/yyyy)
Relationship to You
A-Number
►
A-
C. Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Date of Birth (mm/dd/yyyy)
Relationship to You
A-Number
►
A-
Part 4. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form N-470 Instructions before completing this part.
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 5. has 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 6.
,
prepared this application for me based only upon information I provided or authorized.
Form N-470 12/23/16 N
Page 3 of 7
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