Form N-300 - Application To File Declaration Of Intention
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3OMB No. 1615-0078; Expires 09/30/2012
N-300, Application to File
Department of Homeland Security
Declaration of Intention
U.S. Citizenship and Immigration Services
For USCIS Use Only
START HERE - Please type or print in black ink.
Part 1. Information about you.
Returned
Receipt
(NOTE: Applicant must complete
all three pages of this form.)
Family Name
Given Name
Middle Name
Resubmitted
Address - C/O
Street Number and Name
Apt. #
Reloc Sent
City
State or Province
Country
Zip/Postal Code
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship
Reloc Rec'd
U.S. Social Security # (If any)
A# (If any)
Telephone Number
E-Mail Address (If any)
Applicant
Interviewed
Part 2. Processing Information.
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
Action Block
period of six months or longer?
Attach a list of departure/arrival dates of all
No
Yes
absences.
Read the information on penalties in the instructions before
Part 3. Signature.
completing this section. You must be in the United States when you
file this application. You must sign your name below and also sign
your name in the appropriate places (Signature of Applicant on Pages
2 and 3) of this form.
I desire to declare my intention to become a citizen of the United States. I certify, under penalty
of perjury under the laws of the United States of America, that this application and the evidence
submitted with it is all true and correct. I authorize release of any information from my records
that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am
seeking.
Signature
Date
Part 4. Signature of person preparing form, if other than above.
(Sign below.)
I declare that I prepared this application at the request of the above person, and it is based on all
information of which I have any knowledge.
Signature
Date
Print Your Name
To Be Completed by
Attorney or Representative, if any
Firm Name
Fill in box if G-28 is attached to
represent the applicant.
Firm Address
ATTY State License #
Telephone Number
E-Mail Address (If any)
Form N-300 (10/30/11) N
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