OMB NO. 1615-0051; Expires 10/31/2017 Department of Homeland Security U.S. Citizenship and Immigration Services N-4, Monthly Report on Naturalization Papers Office of the Clerk of the (County or District) Date: Court (City, State, and Zip Code) U.S. Citizenship and Immigration Services: In compliance with the naturalization laws and regulations, listed below are each oath administration ceremony conducted under the jurisdiction of the above named court during the month and year. I have also enclosed the duplicate court list endorsed by me as clerk of the above named court during the same month, except for those that have already been delivered personally to your representative. Those so delivered are indicated by an (*) next to the court list number. Also enclosed are ( each endorsed court list. ) voided Certificates of Naturalization. A specific listing of the voided certificates may be found on (Clerk of Court) By (Deputy Clerk) Date of Ceremony Court List Number Place of Ceremony Number of Persons Administered Oath Number of Voided Certificates Form N-4 (Rev. 10/16/15) Y American LegalNet, Inc. www.FormsWorkFlow.com Instructions This form is to be submitted monthly by the clerk of any court conducting naturalization activities in conformity with Section 339 of the Immigration and Nationality Act (8 USC 1450), and Title 8, Code of Federal Regulations, Part 339. The completed form, with a copy and all attachments, should be submitted to the District Office of U.S. Citizenship and Immigration Services (USCIS) having jurisdiction over the location of the court. The USCIS office receiving the form shall retain the duplicate and all attachments, and forward the original to: U. S. Citizenship and Immigration Services Headquarters Office of Field Operations 111 Massachusetts Avenue, N.W., 2nd Floor Washington, D.C. 20529 Authority to Collect Information Our authority for collecting the information reported on Form N-4 is contained in Section 339 of the Immigration and Nationality Act (INA) (8 USC 145D). The information contained in this form will be used by USCIS to finalize the record process regarding persons naturalized and to determine payments to the courts as provided in Section 344(f) of the INA (8 USC 1455). Paperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, 20 Massachusetts Avenue, N.W., Washington, DC 20529-2140. OMB No. 1615-0051. Do not mail your completed Form N-4 to this address. Form N-4 (Rev. 10/16/15) Y American LegalNet, Inc. www.FormsWorkFlow.com