Citizenship Application Form

Page 1

Part 1. Information About Your Eligibility

Date

Age

Basis for Eligibility

You are at least 18 years of age and:

Have been a lawful permanent resident for at least 5 years Have been a lawful permanent resident for at least 3 years and are married to a U.S. citizen Are the lawful permanent resident child of a U.S. citizen parent Are a member of the U.S. armed forces applying based on military service Other

USCIS Field Office

Page 2

Page 3

Request for Disability Accommodations

1. Are you requesting an accommodation because of your disabilities and/or impairments?

Yes No

A. I am deaf or hard of hearing

This applies to me

I am deaf or hard of hearing and request the following accommodation

B. I am blind or have low vision

This applies to me

I am blind or have low vision and request the following accommodation

C. I have another type of disability or impairment

This applies to me

I have another type of disability and/or impairment (for example, use of a wheelchair)

Page 4

Part 4. Information to Contact You

1. Daytime Telephone Number

2. Work Telephone Number (if any)

3. Evening Telephone Number

4. Mobile Telephone Number (if any)

5. Email Address (if any)

Page 5

Part 5. Information About Your Residence

Addresses During the Last 5 Years

A. Current Physical Address

Street Address

City

State / Province

ZIP / Postal Code

Date From

Date Until

B. Current Mailing Address (if different from address above)

Street Address

City

State / Province

ZIP / Postal Code

C. Physical Address 2

Street Address

City

State / Province

ZIP / Postal Code

Date From

Date Until

D. Physical Address 3

Street Address

City

State / Province

ZIP / Postal Code

Date From

Date Until

E. Physical Address 4

Street Address

City

State / Province

ZIP / Postal Code

Date From

Date Until

Additional Physical Addresses

Page 6

Part 6. Information About Your Parents

Neither of my parents is a U.S. citizen

This applies to me

1. Were your parents married before your 18th birthday?

Yes No

Information About Your Mother

2. Is your mother a U.S. citizen?

Yes No

A. Current Legal Name of U.S. Citizen Mother

First Name

Last Name

B. Mother's Country of Birth

C. Mother's Date of Birth

D. Date Mother Became a U.S. Citizen (if known)

E. Mother's A-Number (if any)

Information About Your Father

3. Is your father a U.S. citizen?

Yes No

A. Current Legal Name of U.S. Citizen Father

First Name

Last Name

B. Father's Country of Birth

C. Father's Date of Birth

D. Date Father Became a U.S. Citizen (if known)

E. Father's A-Number (if any)

Page 7

Page 8

Part 8. Employment and School History

1. Employer or School Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

Date From

Date To

Your Occupation

2. Employer or School Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

Date From

Date To

Your Occupation

3. Employer or School Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

Date From

Date To

Your Occupation

4. Employer or School Name

Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

Date From

Date To

Your Occupation

Add More

Yes, I have more employers or schools to add

Additional Employer or School Information

Page 9

Part 9. Time Outside the United States

1. How many total days (24 hours or longer) have you spent outside the United States during the last 5 years?

2. How many trips of 24 hours or longer have you taken outside the United States during the last 5 years?

Page 10

Page 11

Part 11. Information About Your Children

1. Indicate the total number of your children (include all: living, missing, or deceased; born in the U.S. or abroad; under or over 18; married or unmarried; living with you or elsewhere; current stepchildren; legally adopted children; and children born when you were not married)

Information for Each Child

A. Child 1 Current Legal Name

First Name

Last Name

Date of Birth

Country of Birth

Current Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

What is your child's relationship to you? (for example, biological child, stepchild, legally adopted child)

B. Child 2 Current Legal Name

First Name

Last Name

Date of Birth

Country of Birth

Current Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

What is your child's relationship to you? (for example, biological child, stepchild, legally adopted child)

C. Child 3 Current Legal Name

First Name

Last Name

Date of Birth

Country of Birth

Current Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

What is your child's relationship to you? (for example, biological child, stepchild, legally adopted child)

D. Child 4 Current Legal Name

First Name

Last Name

Date of Birth

Country of Birth

Current Address

Street Address

City

State / Province

ZIP / Postal Code

Province or Region

Postal Code

Country

What is your child's relationship to you? (for example, biological child, stepchild, legally adopted child)

Page 12

Part 12. Additional Information About You

1. Have you EVER claimed to be a U.S. citizen (in writing or any other way)?

Yes No

Explain

2. Have you EVER registered to vote in any Federal, state, or local election in the United States?

Yes No

Explain

3. Have you EVER voted in any Federal, state, or local election in the United States?

Yes No

Explain

4. A. Do you now have, or have you EVER had, a hereditary title or order of nobility in any foreign country?

Yes No

Explain

4. B. If you answered "Yes," are you willing to give up any inherited titles or orders of nobility in a foreign country at your naturalization ceremony?

Yes No

Explain

5. Have you EVER been declared legally incompetent or confined to a mental institution?

Yes No

Explain

6. Do you owe any overdue Federal, state, or local taxes?

Yes No

Explain

7. A. Have you EVER failed to file a Federal, state, or local tax return since becoming a lawful permanent resident?

Yes No

7. B. If you answered "Yes," did you consider yourself a "non-U.S. resident"?

Yes No

Explain

8. Have you called yourself a "non-U.S. resident" on a Federal, state, or local tax return since becoming a lawful permanent resident?

Yes No

Explain

9. A. Have you EVER been a member of, involved in, or in any way associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or elsewhere in the world?

Yes No

Explain

11. Have you EVER advocated (directly or indirectly) the overthrow of any government by force or violence?

Yes No

Explain

12. Have you EVER persecuted (directly or indirectly) any person because of race, religion, national origin, membership in a particular social group, or political opinion?

Yes No

Explain

17. Were you EVER part of any group, unit, or organization that used a weapon against any person, or threatened to do so?

Yes No

Explain

A. If you answered "Yes," while part of or helping this group, did you ever use a weapon against another person?

Yes No

Explain

B. If you answered "Yes," while part of or helping this group, did you ever tell another person you would use a weapon against them?

Yes No

Explain

18. Did you EVER sell, give, or provide weapons to any person, or help another person do so?

Yes No

Explain

A. If you answered "Yes," did you know this person was going to use the weapons against another person?

Yes No

Explain

B. If you answered "Yes," did you know this person was going to sell or give the weapons to someone who would use them against another person?

Yes No

Explain

19. Did you EVER receive any type of military, paramilitary, or weapons training?

Yes No

Explain

20. Did you EVER recruit, enlist, conscript, or use any person under 15 years of age to serve in or help an armed force or group?

Yes No

Explain

21. Did you ever use any person under 14 years of age to do anything that helped or supported people in combat?

Yes No

Explain

Criminal History

22. Have you EVER committed, assisted in committing, or attempted to commit a crime or offense for which you were NOT arrested?

Yes No

23. Have you EVER been arrested, cited, or detained by any law enforcement officer (including immigration or U.S. armed forces officials) for any reason?

Yes No

24. Have you EVER been charged with committing, attempting to commit, or assisting in committing a crime or offense?

Yes No

25. Have you EVER been convicted of a crime or offense?

Yes No

26. Have you EVER been placed in an alternative sentencing or rehabilitative program (for example, diversion, deferred prosecution, withheld or deferred adjudication)?

Yes No

27. A. Have you EVER received a suspended sentence, been placed on probation, or been paroled?

Yes No

B. If you answered "Yes," have you completed the probation or parole?

Yes No

28. A. Have you EVER been in jail or prison?

Yes No

Time Served

Years

Months

Days

Continued: Additional Information

31. Have you ever given any U.S. Government officials information that was false, fraudulent, or misleading?

Yes No

32. Have you ever lied to any U.S. Government officials to gain entry to the United States or to obtain immigration benefits while in the United States?

Yes No

33. Have you ever been removed, excluded, or deported from the United States?

Yes No

34. Have you ever been ordered removed, excluded, or deported from the United States?

Yes No

35. Have you ever been placed in removal, exclusion, rescission, or deportation proceedings?

Yes No

36. Are removal, exclusion, rescission, or deportation proceedings (including administratively closed proceedings) currently pending against you?

Yes No

37. Have you ever served in the U.S. armed forces?

Yes No

38. A. Are you currently a member of the U.S. armed forces?

Yes No

38. B. If you answered "Yes," are you scheduled to deploy overseas, including to a vessel, within the next three months?

Yes No

38. C. If you answered "Yes," are you currently stationed overseas?

Yes No

39. Have you EVER been court-martialed, administratively separated, or disciplined, or received an other-than-honorable discharge, while in the U.S. armed forces?

Yes No

40. Have you EVER been discharged from training or service in the U.S. armed forces because you were an alien?

Yes No

41. Have you EVER left the United States to avoid being drafted into the U.S. armed forces?

Yes No

42. Have you EVER applied for any kind of exemption from military service in the U.S. armed forces?

Yes No

43. Have you EVER deserted from the U.S. armed forces?

Yes No

44. A. Are you a male who lived in the United States at any time between the ages of 18 and 26? (This does not include living in the U.S. as a lawful nonimmigrant.)

Yes No

Selective Service Registration

Date Registered

Supporting Documentation

Attachment

Max 10 MB per file

Oath Requirements

45. Do you support the Constitution and form of government of the United States?

Yes No

46. Do you fully understand the Oath of Allegiance to the United States?

Yes No

46. Do you fully understand the Oath of Allegiance to the United States?

Yes No

47. Are you willing to take the full Oath of Allegiance to the United States?

Yes No

48. If the law requires it, are you willing to bear arms on behalf of the United States?

Yes No

49. If the law requires it, are you willing to perform noncombatant service in the U.S. armed forces?

Yes No

50. If the law requires it, are you willing to perform work of national importance under civilian direction?

Yes No

Attachment

Max 10 MB per file

Page 13

Part 13. Applicant's Statement

A. I can read and understand English

I confirm this statement

B. An interpreter read this application to me in my language

I confirm this statement

Language

2. Applicant's Statement Regarding the Preparer

I confirm this statement

Preparer

Applicant's Certification

Applicant's Signature

Sign here

Date of Signature

Page 14

Part 14. Interpreter's Contact Information

Full Name

First Name

Last Name

2. Interpreter's Business or Organization Name (if any)

Interpreter's Address

3. Address

Street Address

City

State / Province

ZIP / Postal Code

Interpreter's Contact Information

4. Interpreter's Daytime Phone Number

5. Interpreter's Mobile Phone Number (if any)

6. Interpreter's Email Address (if any)

Interpreter's Certification

Language

Interpreter's Signature Block

Interpreter's Signature

Sign here

Date of Signature

Page 15

Part 15. Information About the Preparer

Full Name

First Name

Last Name

2. Preparer's Business or Organization Name (if any)

Preparer's Address

3. Address

Street Address

City

State / Province

ZIP / Postal Code

Preparer's Contact Information

4. Preparer's Daytime Phone Number

5. Preparer's Mobile Phone Number (if any)

6. Preparer's Email Address (if any)

Preparer's Certification

A. I prepared this application at the applicant's request

I confirm this statement

B. This is based on information the applicant provided to me

I confirm this statement

Is the preparer an attorney or accredited representative?

Yes No

Additional Preparer Information

Certification Statement

Preparer's Signature Block

Preparer's Signature

Sign here

Date of Signature

Part 16. Additional Information

USCIS Officer Use Only

Officer's Certification

USCIS Officer's Printed Name or Stamp

Date of Signature

Applicant's Signature

Sign here

USCIS Officer's Signature

Sign here

Additional Information (Continued)

Additional Titles (if applicable)

Applicant's Printed Name

Applicant's Signature

Sign here

USCIS Officer's Printed Name

USCIS Officer's Signature

Sign here

Date of Signature

Final Certification

Applicant's Printed Name

First Name

Last Name

Applicant's Signature

Sign here

Date of Signature

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Citizenship Application Form

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