Application to File Declaration of Intention

• Legal Form Number: N-300
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

To be completed by an

attorney or accredited

representative (if any).

Date Stamp

RemarksBar Code

START HERE - Type or print in black ink.

Action BlockReceipt

Application to File Declaration of Intention

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form N-300

Part 1. Information About You

1.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 Nationality

6.

(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)

YesNo

If 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

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Form N-300 Edition 12/02/19