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Fillable Printable Form N-470

Fillable Printable Form N-470

Form N-470

Form N-470

Form N-470 12/23/16 NPage 1 of 7
Application to Preserve Residence
for Naturalization Purposes
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form N-470
OMB No. 1615-0056
Expires 05/31/2019
Date Stamp
Attorney State Bar Number
(if applicable)
Select this box if
Form G-28 is
attached.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
To be completed by an
attorney or accredited
representative (if any).
ForUSCISUseOnly
Remarks
START HERE - Type or print in black ink.
A-
Barcode
Action Block
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-470.
Part 1. Information About Your Eligibility
My absence from the United States is on behalf of (Select only one box):
1.The U.S. Government (employed by, or are under contract with, the U.S. Government).
2.An American institution of research to perform scientific research.
3.An American firm or corporation, or a subsidiary thereof, to engage in the development of foreign trade and commerce of the
United States.
4.An American firm or corporation to protect the property rights outside the United States of that American firm or corporation
engaged in the development of foreign trade and commerce of the United States.
5.A public international organization of which the United States is a member. (Your employment must have started after your
admission as a lawful permanent resident.)
6.A denomination or mission having a bona fide organization in the United States in which I perform ministerial or priestly
functions or my sole capacity is of a clergyman or clergywoman, missionary, brother, nun, or sister.
Part 2. Information About You
Family Name (Last Name)Given Name (First Name)Middle Name
Your Current Legal Name (do not provide a nickname)1.
Enter Your 9 Digit A-Number:
Family Name (Last Name)Given Name (First Name)Middle Name
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 7. Additional Information.
2.
Form N-470 12/23/16 NPage 2 of 7
7.Country of Birth 8.Country of Citizenship or Nationality
Part 2. Information About You (continued)
Physical Address (do not provide a PO Box in this space unless it is your only address)9.
Street Number and NameApt.Flr.NumberSte.
City or Town
StateZIP Code
Postal CodeProvinceCountry
Mailing Address (if different from the address above)10.
Street Number and NameApt.Flr.NumberSte.
City or TownStateZIP Code
Postal CodeProvinceCountry
In Care Of Name (if any)
11.
12.
Date You Became a Lawful Permanent Resident (mm/dd/yyyy)
13.
Have you resided in and been physically present in the United States for an uninterrupted period of at least
one year since your admission as a lawful permanent resident? (If you answer “No,” provide an
explanation in the space provided in Part 7. Additional Information.)
NoYes
Time Outside the United States (include trips to Canada, Mexico, and the Caribbean)
Provide all the trips of 24 hours or more that you have taken outside the United States since you became a lawful permanent
resident. Begin with your most recent trip. If you need extra space to complete this section, use the space provided in Part 7.
Additional Information.
Date You Left the
United States
(mm/dd/yyyy)
Date You Returned
to the United States
(mm/dd/yyyy)
Did Trip Last
Six Months or
More?
Countries You Traveled To
Total Days
Outside the
United States
NoYes
NoYes
NoYes
NoYes
U.S. Social Security Number (if any)5.
Date of Birth (mm/dd/yyyy)
6.
Family Name (Last Name)Given Name (First Name)Middle Name
Your name exactly as it appears on your Permanent Resident Card
3.
A-
4.USCIS Online Account Number (if any)
Form N-470 12/23/16 NPage 3 of 7
Part 3. Information About Family Members Who Reside With You
Do you have lawful permanent resident family members who reside with you inside the United States?1.NoYes
If you answered "Yes" to Item Number 1., will those family members reside with you outside the United
States?
2.NoYes
If you answered “Yes,” provide the information below for each lawful permanent resident family member who will be residing
with you outside the United States. If you need extra space to complete this section, use the space provided in Part 7. Additional
Information.
A.
Family Name (Last Name)Given Name (First Name)Middle Name (if applicable)
A-NumberDate of Birth (mm/dd/yyyy)
A-
Relationship to You
B.
Family Name (Last Name)Given Name (First Name)Middle Name (if applicable)
A-NumberDate of Birth (mm/dd/yyyy)
A-
Relationship to You
C.
Family Name (Last Name)Given Name (First Name)Middle Name (if applicable)
A-NumberDate of Birth (mm/dd/yyyy)
A-
Relationship to You
14.
15.Have you ever filed an income tax return as a nonresident or otherwise claimed or received benefits as a
nonresident alien under U.S. Federal, state or local income tax laws since you became a lawful
permanent resident?
Explain your employment position requiring your absence from the United States and the intended length of employment.
NoYes
Part 2. Information About You (continued)
A-
Part 4. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form N-470 Instructions before completing this part.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
Applicant's Statement
I can read and understand English, and I have read and understand every question and instruction on this application and
my answer to every question.
A.
prepared this application for me based only upon information I provided or authorized.
At my request, the preparer named in Part 6.,
2.Applicant's Statement Regarding the Preparer
every question, in
The interpreter named in Part 5. has read to me every question and instruction on this application and my answer to
, a language in which I am fluent and I understood
B.
1.Applicant's Statement Regarding the Interpreter
everything.
Form N-470 12/23/16 NPage 4 of 7
Part 4. Applicant's Statement, Contact Information, Certification, and
Signature (continued)
A-
5.Applicant's Email Address (if any)
Applicant's Contact Information
3.4.
Applicant's Daytime Telephone NumberApplicant's Mobile Telephone Number (if any)
Applicant's Certification
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 application, 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 I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.
Applicant's Signature
Applicant's SignatureDate of Signature (mm/dd/yyyy)6.
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.
Part 5. Interpreter's Contact Information, Certification, and Signature
Interpreter's Given Name (First Name)Interpreter's Family Name (Last Name)1.
Provide the following information about the interpreter.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Interpreter's Mailing Address
3.Street Number and NameApt.Flr.NumberSte.
City or TownStateZIP Code
Postal CodeProvinceCountry
Form N-470 12/23/16 NPage 5 of 7
Part 5. Interpreter's Contact Information, Certification, and Signature
(continued)
A-
Interpreter's Contact Information
4.Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
5.Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,which is the same language specified in Part 4.,
Item B., in Item Number 1.;andI have read to this applicant in the identified language every question and instruction on this
application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question,
and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer.
Date of Signature (mm/dd/yyyy)Interpreter's Signature
Interpreter's Signature
7.
Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
Preparer's Given Name (First Name)Preparer's Family Name (Last Name)1.
Preparer's Business or Organization Name (if any) 2.
Preparer's Mailing Address
3.Street Number and NameApt.Flr.NumberSte.
City or TownStateZIP Code
Postal CodeProvinceCountry
Form N-470 12/23/16 NPage 6 of 7
Part 6. Contact Information, Declaration, and Signature of the Person
Preparing this Application, if Other Than the Applicant (continued)
A-
Preparer's Contact Information
Preparer's Daytime Telephone Number Preparer's Mobile Telephone Number (if any)
Preparer's Email Address (if any)
4.
6.
5.
I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with
the applicant's consent.
I am an attorney or accredited representative and my representation of the applicant in this case
does not extend beyond the preparation of this application.
7.A.
B.
extends
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this
application, you may be obliged to submit a completed Form G-28, Notice of Attorney or Accredited Representative,
with this application.
Preparer's Certification
Preparer's Signature Date of Signature (mm/dd/yyyy)
Preparer's Signature
8.
By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.
Preparer's Statement
Form N-470 12/23/16 NPage 7 of 7
Part 7. Additional Information
If you need extra space to provide any additional information within this application, 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 application or attach a separate sheet of paper.
Type or print 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.
A-Number (if any)
A-
3.
2.
Page NumberB.Part NumberC.Item Number
D.
A.
A.
A.
A.
Page Number
5.
Page Number
Part NumberItem NumberC.B.
D.
6.
D.
B.C.
Item NumberPart NumberPage Number
Part NumberItem Number
1.Family Name (Last Name) Given Name (First Name) Middle Name
C.B.
D.
4.
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