Application to Preserve Residence for Naturalization Purposes Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form N-470 OMB No. 1615-0056 Expires 05/31/2019 For USCIS Use Only Barcode Date Stamp Action Block Remarks To be completed by an attorney or accredited representative (if any). 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) START HERE - Type or print in black ink. NOTE: Type or print "N/A" if an item is not applicable. Type or print "None" if the answer is none. Failure to answer all of the questions may delay your Form N-470. Enter Your 9 Digit A-Number: Part 1. Information About Your Eligibility My absence from the United States is on behalf of (Select only one box): 1. 2. 3. 4. 5. 6. The U.S. Government (employed by, or are under contract with, the U.S. Government). An American institution of research to perform scientific research. A- An American firm or corporation, or a subsidiary thereof, to engage in the development of foreign trade and commerce of the United States. An American firm or corporation to protect the property rights outside the United States of that American firm or corporation engaged in the development of foreign trade and commerce of the United States. A public international organization of which the United States is a member. (Your employment must have started after your admission as a lawful permanent resident.) A denomination or mission having a bona fide organization in the United States in which I perform ministerial or priestly functions or my sole capacity is of a clergyman or clergywoman, missionary, brother, nun, or sister. Part 2. Information About You 1. Your Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used (if any) List 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 7. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name Form N-470 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 Part 2. Information About You (continued) 3. Your name exactly as it appears on your Permanent Resident Card Family Name (Last Name) Given Name (First Name) A- Middle Name 4. USCIS Online Account Number (if any) 5. U.S. Social Security Number (if any) 6. Date of Birth (mm/dd/yyyy) 7. Country of Birth 8. Country of Citizenship or Nationality 9. Physical Address (do not provide a PO Box in this space unless it is your only address) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 10. Mailing Address (if different from the address above) In Care Of Name (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 11. Date You Became a Lawful Permanent Resident (mm/dd/yyyy) 12. Have you resided in and been physically present in the United States for an uninterrupted period of at least one year since your admission as a lawful permanent resident? (If you answer "No," provide an explanation in the space provided in Part 7. Additional Information.) 13. Time Outside the United States (include trips to Canada, Mexico, and the Caribbean) Provide all the trips of 24 hours or more that you have taken outside the United States since you became a lawful permanent resident. Begin with your most recent trip. If you need extra space to complete this section, use the space provided in Part 7. Additional Information. Date You Left the Date You Returned Did Trip Last United States to the United States Six Months or (mm/dd/yyyy) (mm/dd/yyyy) More? Yes Yes Yes Yes No No No No Countries You Traveled To Total Days Outside the United States Yes No Form N-470 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Part 2. Information About You (continued) A- 14. Explain your employment position requiring your absence from the United States and the intended length of employment. 15. Have you ever filed an income tax return as a nonresident or otherwise claimed or received benefits as a nonresident alien under U.S. Federal, state or local income tax laws since you became a lawful permanent resident? Yes No Part 3. Information About Family Members Who Reside With You 1. 2. Do you have lawful permanent resident family members who reside with you inside the United States? If you answered "Yes" to Item Number 1., will those family members reside with you outside the United States? Yes Yes No No If you answered "Yes," provide the information below for each lawful permanent resident family member who will be residing with you outside the United States. If you need extra space to complete this section, use the space provided in Part 7. Additional Information. A. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Date of Birth (mm/dd/yyyy) Relationship to You A-Number AB. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Date of Birth (mm/dd/yyyy) Relationship to You A-Number AC. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Date of Birth (mm/dd/yyyy) Relationship to You A-Number A- Part 4. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form N-470 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. B. 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. The interpreter named in Part 5. has read to me every question and instruction on this application and my answer to every question, in everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 6. prepared this application for me based only upon information I provided or authorized. American LegalNet, Inc. www.FormsWorkFlow.com , a language in which I am fluent and I understood , Page 3 of 7 Form N-470 12/23/16 N Part 4. Applicant's Statement, Contact Information, Certification, and Signature (continued) Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. A- Applican