U.S. Social Security # (If any)
ATTY State License #
START HERE - Please type or print in black ink.
Part 1. Information about you. (NOTE: Applicant must complete
all three pages of this form.)
Address - C/O
Street Number and Name
State or Province
Date of Birth (mm/dd/yyyy)
Country of Citizenship
A# (If any)
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
period of six months or longer?
Read the information on penalties in the instructions before
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
Part 4. Signature of person preparing form, if other than above.
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.
Print Your Name
Attach a list of departure/arrival dates of all
Part 3. Signature.
To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the applicant.
For USCIS Use Only
Country of Birth
N-300, Application to File
Declaration of Intention
OMB No. 1615-0078; Expires 07/31/09