Uscis Form N-400 - Application For Naturalisation Page 2
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20Part 2. Information About You (Person applying for naturalization) (continued)
A-
3.
Other Names You Have Used Since Birth (include nicknames, aliases, and maiden name, if applicable)
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
4.
Name Change (Optional)
Read the Form N-400 Instructions before you decide whether or not you would like to legally change your name.
Would you like to legally change your name?
Yes
No
If you answered ''Yes," type or print the new name you would like to use in the spaces provided below.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
5.
U.S. Social Security Number (if applicable)
6.
USCIS Online Account Number (if any)
►
►
8.
9.
Date You Became a Lawful
7.
Gender
Date of Birth
Permanent Resident (mm/dd/yyyy)
(mm/dd/yyyy)
Male
Female
Country of Citizenship or Nationality
10.
Country of Birth
11.
12.
Do you have a physical or developmental disability or mental impairment that prevents you from
Yes
No
demonstrating your knowledge and understanding of the English language and/or civics requirements
for naturalization?
If you answered "Yes," submit a completed Form N-648, Medical Certification for Disability Exceptions, when you file your
Form N-400.
13.
Exemptions from the English Language Test
A. Are you 50 years of age or older and have you lived in the United States as a lawful permanent
Yes
No
resident for periods totaling at least 20 years at the time you file your Form N-400?
B. Are you 55 years of age or older and have you lived in the United States as a lawful permanent
Yes
No
resident for periods totaling at least 15 years at the time you file your Form N-400?
C. Are you 65 years of age or older and have you lived in the United States as a lawful permanent
Yes
No
resident for periods totaling at least 20 years at the time you file your Form N-400? (If you meet
this requirement, you will also be given a simplified version of the civics test.)
Part 3. Accommodations for Individuals With Disabilities and/or Impairments
NOTE: Read the information in the Form N-400 Instructions before completing this part.
1.
Are you requesting an accommodation because of your disabilities and/or impairments?
Yes
No
If you answered "Yes," select any applicable box.
A.
I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language
interpreter, indicate for which language (for example, American Sign Language).)
B.
I am blind or have low vision and request the following accommodation:
Form N-400 09/29/16 Y
Page 2 of 20
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