Request for Certification of Military or Naval Service Department of Homeland Security U.S. Citizenship and Immigration Services OMB No. 1615-0053 Expires 08/31/2017 USCIS Form N-426 Persons who are serving or have served under specified conditions in the U.S. Armed Forces are granted certain exemptions from the general requirements for naturalization. To establish eligibility, the law requires the department with custody of the service record to certify whether the service member served honorably, and whether each separation from the service was under honorable conditions. USCIS requests certification of the service member's military service. Recruiters are not authorized to certify this request. Submit this request with Form N-400, Application for Naturalization. Instructions: Requestors must complete Parts 1. - 4. Certifying officials must complete Parts 5. - 8. Part 1. Information About You 1. 3. Alien Registration Number (A-Number) (if any) ANames Used During Military Service List all names you have used, including your maiden name (if any). 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 2. Military Service Number 4. 7. 8. U.S. Social Security Number (if any) 5. Place of Birth (city and country) Physical Address Street Number and Name City or Town Province or Region (foreign address only) USCIS ELIS Account Number (if any) 6. Date of Birth (mm/dd/yyyy) Apt. Ste. Flr. Number County Country (foreign address only) State ZIP Code + 4 - Postal Code (foreign address only) Part 2. Enlistment Information 1. Where did you enlist? City State Country 2. 3. Have you reenlisted? Where did you reenlist? City Yes No State Country Form N-426 08/04/2015 Y Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Periods of Military Service (To be completed by requestor) Provide all periods of service. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Military Service Military Service 1 Military Service 2 Military Service 3 Branch of Service Date Service Began (mm/dd/yyyy) Date Service Ended (mm/dd/yyyy) Type of Service (include all active, reserve, and National Guard Service) Active Duty Selected Reserve of the Ready Reserve* Active Duty Selected Reserve of the Ready Reserve* Active Duty Selected Reserve of the Ready Reserve* * Selected Reserve of the Ready Reserve Members: (1) participate in at least 48 scheduled drills or training periods during each year and serve on active duty for training at least 14 days a year or (2) participate in training at encampments, maneuvers, outdoor target practice, or other exercises at least 15 days each year. (10 U.S.C. 10143) Part 4. Requestor's Contact Information, Certification, and Signature Requestor's Contact Information 1. 3. Requestor's Daytime Telephone Number Requestor's Email Address (if any) 2. Requestor's Mobile Telephone Number (if any) Requestor's Certification I 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 certify, under penalty of perjury, that the information in my request and any document submitted with my request were provided by me and are complete, true, and correct. Requestor's Signature 4. Requestor's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL REQUESTORS: USCIS may deny your request if you do not completely fill out this request or fail to submit required documents listed in the instructions. Part 5. Character of Service (To be completed by Certifying Official) State whether the requestor served honorably or is currently serving honorably for each period of military service the requestor served (refer to Part 3. Periods of Military Service). If you answer "No," provide details in Part 7. Remarks. 1. 2. 3. Honorable Period of Military Service 1 Honorable Period of Military Service 2 Honorable Period of Military Service 3 Yes Yes Yes No No No Form N-426 08/04/2015 Y Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 6. Separation Information 1. 2. 3. Is the requestor separated? If separated, select discharge type: Was the requestor discharged on account of alienage? If you answer "Yes," provide details in Part 7. Remarks. Honorable Yes No Other (provide details in Part 7. Remarks) Yes No Part 7. Remarks Provide any derogatory information in your records relating to the service member's character, loyalty to the United States, disciplinary action, convictions, other than honorable discharges, or other matters concerning his or her fitness for citizenship. If you need extra space to complete this section, use the space provided in Part 9. Additional Information. Part 8. Certification (To be completed by Certifying Official) I am authorized to certify that the information given here concerning the service of the person named on this request is correct according to the records of the Name of Department Official Signature Daytime Telephone Number Name and Title Email Address (if any) Date (mm/dd/yyyy) Seal, if available (No state-issued notary public seals accepted.) Form N-426 08/04/2015 Y Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 9. Additional Information If you need extra space to provide any additional information within this request, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1. Family Name (Last Name) Given Name (First Name) Middle Name 2. 3. A-Number (if any) AA. Page Number D. B. Part Number C. Item Number 4. A. Page Number D. B. Part Number C. Item Number 5. A. Page Number D. B. Part Number C. Item Number 6. A. Page Number D. B. Part Number C. Item Number Form N-426 08/04/2015 Y Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com