Request for a Hearing on a Decision in Naturalization Proceedings Under Section 336 Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form N-336 OMB No. 1615-0050 Expires 05/31/2019 For USCIS Use Only Barcode Date Stamp Remarks Re-Affirm N-400 Denial To be completed by an attorney or accredited representative (if any). Re-Determine N-400 Denial 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-336. Enter Your 9 Digit A-Number: Part 1. Information About You, the Naturalization Applicant 1. Current Legal Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) A- 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 9. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name 3. Date of Birth (mm/dd/yyyy) 4. USCIS Online Account Number (if any) 5. 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 County State ZIP Code + 4 - Province or Region (foreign address only) Postal Code (foreign address only) Country (foreign address only) Form N-336 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 8 Part 1. Information About You, the Naturalization Applicant (continued) 6. Mailing Address In Care Of Name (if any) A- Street Number and Name Apt. Ste. Flr. Number City or Town County State ZIP Code + 4 - Province or Region (foreign address only) Postal Code (foreign address only) Country (foreign address only) 7. Contact Information A. Daytime Telephone Number B. Work Telephone Number (if any) C. Evening Telephone Number D. Mobile Telephone Number (if any) E. Email Address (if any) Part 2. Information About Form N-400 Denial On Which You (the Naturalization Applicant) Are Requesting a Hearing 1. Form N-400 Receipt Number 2. Date of Form N-400 Denial Notice (mm/dd/yyyy) 3. USCIS Office That Issued Form N-400 Denial Notice Part 3. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino 2. Not Hispanic or Latino Race (Select all applicable boxes) White Asian Black or African American Inches American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 3. 4. 5. Height Weight Feet Pounds Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/ Other Page 2 of 8 Form N-336 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Reason You Are Requesting a Hearing A- Provide the reasons you are requesting a hearing on your denied Form N-400. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. NOTE: Refer to the What Evidence Must You Submit section of Form N-336 Instructions for documents to submit with your Form N-336. Form N-336 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 8 Part 5. Accommodations for Individuals With Disabilities and/or Impairments NOTE: Read the information in the Form N-336 Instructions before completing this part. 1. Are you requesting an accommodation because of your disabilities and/or impairments? If you answered "Yes" to Item Number 1., select any applicable box. A. A- Yes No I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language interpreter, indicate for which language (for example, American Sign Language).) B. I am blind or have low vision and request the following accommodation: C. I have another type of disability and/or impairment. (Describe the nature of your disability and/or impairment and the accommodation you are requesting.) Part 6. Naturalization Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form N-336 Instructions before completing this part. Naturalization 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. Naturalization 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 request and my answer to every question. The interpreter named in Part 7. read to me every question and instruction on this request and my answer to every question in understood everything. 2. Naturalization Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 8., prepared this request for me based only upon information I provided or authorized. , , a language in which I am fluent, and I Naturalization Applicant's Contact Information 3. Naturalization Applicant's Daytime Telephone Number 4. Naturalization Applicant's Mobile Telephone Number (if any) 5. Naturalization Applicant's Email Address (if any) Form N-336 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 8 Part 6. Naturalization Applicant's Statement, Contact Information, Certification, and Signature (continued) Naturalization Applicant's Certification A- Copies 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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further authorize release of information contained in this request, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. 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: 1) I reviewed and provided or authorized all of the information in my request; 2) I understood all o