OMB No. 1615-0078; Expires 09/30/2012 N-300, Application to File Declaration of Intention Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Please type or print in black ink. Part 1. Information about you. (NOTE: Applicant must complete For USCIS Use Only Returned Receipt all three pages of this form.) Family Name Given Name Middle Name Resubmitted Address - C/O Street Number and Name City Apt. # State or Province Country Reloc Sent Zip/Postal Code Date of Birth (mm/dd/yyyy) Country of Birth Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number Reloc Rec'd 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 period of six months or longer? No Yes Attach a list of departure/arrival dates of all 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 Action Block 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 American LegalNet, Inc. www.FormsWorkFlow.com Original to be retained by USCIS - Duplicate to be given to: Family Name Given Name Middle Name Address - C/O Street Number and Name Apt. # City Affix State or Province Country Zip/Postal Code Date of Birth (mm/dd/yyyy) Country of Birth Photograph Here Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number E-Mail Address (If any) I am over the age of 18 years, have been lawfully admitted to the United States as a permanent resident, and am now residing in the United States pursuant to such admission. Not valid unless DHS Seal applied below. I hereby declare my intention in good faith to become a citizen of the United States and I certify that the photographs affixed to the original and duplicate hereof are a likeness of me and were signed by me. I do swear (or affirm) that the statements I have made and the intentions I have expressed in this declaration of intention subscribed by me are true to the best of my knowledge and belief. Signature of Applicant Date Original Copy/Retained by USCIS Signature of Authorizing Official Date Form N-300 (10/30/11) N Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Original to be retained by USCIS - Duplicate to be given to: Family Name Given Name Middle Name Address - C/O Street Number and Name Apt. # City Affix State or Province Country Zip/Postal Code Date of Birth (mm/dd/yyyy) Country of Birth Photograph Here Country of Citizenship U.S. Social Security # (If any) A# (If any) Telephone Number E-Mail Address (If any) I am over the age of 18 years, have been lawfully admitted to the United States as a permanent resident, and am now residing in the United States pursuant to such admission. Not valid unless DHS Seal applied below. I hereby declare my intention in good faith to become a citizen of the United States and I certify that the photographs affixed to the original and duplicate hereof are a likeness of me and were signed by me. I do swear (or affirm) that the statements I have made and the intentions I have expressed in this declaration of intention subscribed by me are true to the best of my knowledge and belief. Signature of Applicant Date Duplicate Copy/Given to Applicant Signature of Authorizing Official Date Form N-300 (10/30/11) N Page 3 American LegalNet, Inc. www.FormsWorkFlow.com