To be completed by an attorney or accredited representative (if any). Date StampRemarksBar CodeSTART HERE - Type or print in black ink. Action BlockReceiptApplication to File Declaration of Intention Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form N-300 OMB No. 1615-0078 Expires 03/31/2020 Part 1.240 Information About You1.Your Current Legal Name (Do not provide a nickname.)Family Name (Last Name) Given Name (First Name) Middle Name 8.Since you were admitted to the United States as a lawful permanent resident, have you been absent for a period of six months or longer?2.Country of Citizenship or Nationality6.(mm/dd/yyyy)Country of Birth Select this box if Form G-28 is attached.Attorney State Bar Number (if applicable)Attorney or Accredited Representative USCIS Online Account Number (if any) Yes NoIf you answered "Yes" to Item Number 9., provide departure/arrival dates of all absences in the space provided in Part 5. Additional Information.4. For USCIS Use Only 3.USCIS Online Account Number (if any)U.S. Social Security Number (if any)Enter Your 9 Digit A-Number: A- Date You Became a Lawful Permanent Resident 7.Other Names Used (if any) 9.Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 5. Additional Information.5.Date of Birth (mm/dd/yyyy)Family Name (Last Name)Given Name (First Name)Middle Name Page 1 of 8 Form N-300 03/13/18 11.Physical Address (if different from the address above) City or TownStateZIP CodeStreet Number and Name (Do not provide a PO Box in this space unless it is your ONLY address.)Apt.Flr.NumberSte. Part 1.240 Information About You (continued) Part 2. Applicant's Statement, Contact Information, Declaration, Certification, and SignatureNOTE: Read the Penalties section of the Form N-300 Instructions before completing this part. You must file Form N-300 while in the United States. NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1.I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. A.Applicant's Statement Regarding the Interpreter question in The interpreter named in Part 3. read to me every question and instruction on this application and my answer to every , a language in which I am B.At my request, the preparer named in Part 4., , prepared this application for me based only upon information I provided or authorized.2.Applicant's Statement Regarding the Preparer Applicant's Contact Information3.4.5.Applicant's Email Address (if any) Applicant's Daytime Telephone Number Applicant's Mobile Telephone Number (if any) A- Mailing Address (USPS ZIP Code Lookup )10. City or TownStateZIP CodeStreet Number and NameApt.Flr.NumberSte. In Care Of Name (if any) Applicant's Statementfluent and I understood everything.240Page 2 of 8Form N-300 03/13/18 NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. Applicant's Declaration and CertificationCopies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek.I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: Applicant's Signature Applicant's SignatureDate of Signature (mm/dd/yyyy) 6. Part 2. Applicant's Statement, Contact Information, Declaration, Certification, and Signature (continued) Part 3. Interpreter's Contact Information, Certification, and Signature Interpreter's Given Name (First Name) Interpreter's Family Name (Last Name)1.Provide the following information about the interpreter. Interpreter's Business or Organization Name (if any)2. Interpreter's Full Name A- 1)I reviewed and understood all of the information contained in, and submitted with, my application; and2)All of this information was complete, true, and correct at the time of filing.I certify, under penalty of perjury, that all of the information in my application, and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. Interpreter's Mailing Address3.Street Number and NameApt.Flr.NumberSte.City or Town StateZIP CodePostal CodeProvince Country Page 3 of 8Form N-300 03/13/18 Part 3. Interpreter's Contact Information, Certification, and Signature (continued) A- Interpreter's CertificationI certify, under penalty of perjury, that:I am fluent in English and , which is the same language provided in Part 2., Item B., in Item Number 1.; and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer. Date of Signature (mm/dd/yyyy)Interpreter's Signature Interpreter's Signature7. Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the ApplicantProvide the following information about the preparer. Preparer's Full Name Preparer's Given Name (First Name) Preparer's Family Name (Last Name)1. Preparer's Business or Organization Name (if any)2. Interpreter's Contact Information4.Interpreter's Daytime Telephone NumberInterpreter's Email Address (if any) 6. 5.Interpreter's Mobile Telephone Number (if any) Preparer's Mailing Address3.Street Number and NameApt.Flr.NumberSte.City or Town StateZIP CodePostal CodeProvince CountryPage 4 of 8Form N-300 03/13/18 Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant (continued) A- I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. I am an attorney or accredited representative and my representation of the applicant in this case does not extend beyond the preparation of this application.7. Preparer's StatementA.B. extendsNOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's CertificationBy my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature Date of Signature (mm/dd/yyyy) Preparer's Signature8. Preparer's Contact InformationPreparer's Daytime Telephone Number Preparer's Mobile Telephone Number (if any)Preparer's Email Address (if any) 4.6.5. Page 5 of 8Form N-300 03/13/18 Part 5. Additional InformationIf you need extra space to provide any additional information within this applicati