Medical Certification For Disability Exceptions Page 3
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4U. S. Department of Justice
OMB # 1115-0205
Medical Cerfication For Disability Expections
Immigration and Naturalization Service
Part I.
THIS SECTION TO BE COMPLETED BY THE APPLICANT
(Please print or type information)
Last Name
First Name
Middle Name
Social Security Number
Address
Alien Number
City
State
Zip Code
Telephone Number
Date of Birth
Sex
I,
authorize
(Applicant's Name)
(Licensed medical doctor or licensed clinical psychologist)
to release all relevant physical and mental health information related to my medical status to the INS for the purpose of
applying for an exception from the English language and U.S. civics testing requirements for naturalization.
I certify
under penalty of perjury pursuant to Title 28 U.S.C. Section 1746, that the information on the form and any evidence
submitted with it is all true and correct.
I am aware that the knowing placement of false information on the Form N-648
and related documents may also subject me to civil penalties under 8 U.S.C. Section 1324c.
Signature
Date
Part II
.
THIS SECTION TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR OR LICENSED CLINICAL
PSYCHOLOGIST (see instructions)
The individual named above is applying for an exception from the English language and U. S. history and civics tests
required of applicants for naturalization.
The Immigration and Naturalization Service's regulations require that
applicants for an exception based on disability submit this certification form, completed by a licensed medical doctor or
licensed clinical psychologist, along with a completed application for naturalization (Form N-400).
Please answer the following questions as clearly and completely as possible, using common terminology and complete words
and phrases.
1. Date of your most recent examination of the applicant. _________ 19 ___
2. Is this your first examination of the individual? Yes____ No ____
If yes, who is the regular attending physician? __________________
3. Based on your examination, describe any findings of a physical or mental disability or impairment which, in your
professional medical opinion, would prevent this applicant from demonstrating knowledge of basic English language
and/or U.S. history and civics.
Describe in detail.
If applicant has a mental disability or impairment, please provide
DSM diagnosis.
Form N-648 (06/24/97) Internet Page 3
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