Form N-400 - Application For Naturalization Page 2
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10Write your USCIS A-Number here:
Part 3. Information About You
A
C. Date You Became a Permanent Resident (mm/dd/yyyy)
A. U.S. Social Security Number
B. Date of Birth (mm/dd/yyyy)
D. Country of Birth
E. Country of Nationality
Yes
No
F. Are either of your parents U.S. citizens? (If yes, see instructions)
G. What is your current marital status?
Single, Never Married
Married
Divorced
Widowed
Marriage Annulled or Other (Explain)
H.
Are you requesting a waiver of the English and/or U.S. History and Government
requirements based on a disability or impairment and attaching Form N-648 with
Yes
No
your application?
I.
Are you requesting an accommodation to the naturalization process because of a
disability or impairment? (See instructions for some examples of accommodations.)
No
Yes
If you answered ''Yes," check the box below that applies:
I am deaf or hearing impaired and need a sign language interpreter who uses the following language:
I use a wheelchair.
I am blind or sight impaired.
I will need another type of accommodation. Explain:
Part 4. Addresses and Telephone Numbers
A. Home Address - Street Number and Name (Do not write a P.O. Box in this space.)
Apartment Number
City
County
State
ZIP Code
Country
B. Care of
Mailing Address - Street Number and Name (If different from home address)
Apartment Number
City
State
ZIP Code
Country
C. Daytime Phone Number (If any)
Evening Phone Number (If any)
E-Mail Address (If any)
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Form N-400 (Rev. 06/17/11) Y Page 2
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