CLIENT QUESTIONNAIRE-NATURALIZATION (CITIZENSHIP)
Full legal name:
First
Middle
Last
Any other names used (include maiden name, if applicable):
As part of the Naturalization process, you have the opportunity to change your name. Do you wish to do so?
If yes, please provide the name you want to use:
.
Date of Birth:
Month
Day
Social Security Number, if any:
-
Year
-
City and country of birth:
City
Country
If you are currently married, please complete the following:
Name of spouse:
First
Middle
Social Security Number of spouse:
City and country of birth of spouse:
-
Last (maiden name)
-
City
Country
Date
Place
Date and place of marriage:
Is your spouse a U.S. Citizen?
If yes, please provide date and place he/she became a U.S. Citizen:
If your spouse is not a U.S. Citizen, please provide the following:
Country of citizenship:
A-number:
Immigration Status in U.S.:
Client Questionnaire-Naturalization (citizenship)
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If you have been previously married, please give the following information for all prior marriages (use reverse side, if
necessary):
Name of ex-spouse:
First
Middle
Last (maiden name)
How was the marriage terminated? (Divorce, death, annulment)
Date and place of marriage:
Date
Place
Date
Place
Date and place of termination:
Date of birth of former spouse:
Month
Date
Social Security Number of former spouse:
-
Year
-
If your current spouse has been previously married, please provide the following information about his/her former spouse(s):
Name of ex-spouse:
First
Middle
Last (maiden name)
Citizenship:
How was the marriage terminated? (Divorce, death, annulment):
Date and place of marriage:
Date and place of termination:
Date
Place
Date
Place
If you have children, please provide the following information for- all children, whether they reside inside or outside the
United States (Use reverse side, if necessary):
Name
Date of Birth
City & Country of Birth
Country of Nationality
Please list the addresses at which you have lived for the past five years. Begin with your current address:
Current address:
Street Address
City
Client Questionnaire-Naturalization (citizenship)
Apartment Number, If any
State
Zip Code
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Year and month moved into this address:
Prior addresses:
Month
Year
Street Address
City
Year and month moved into this address:
Apartment Number, If any
State
Month
Year and month moved out of this address:
Year
Month
Street Address
City
Year and month moved into this address:
Month
Year and month moved out of this address:
State
Month
Year
Apartment Number, If any
State
Zip Code
Year
Month
Street Address
Month
Year and month moved out of this address:
Zip Code
Year
Month
Year and month moved out of this address:
City
Year and month moved into this address:
Year
Apartment Number, If any
Street Address
City
Year and month moved into this address:
Zip Code
Year
Apartment Number, If any
State
Zip Code
Year
Month
Year
If you need more space to list more addresses, please use additional paper.
Employment history: Please list all your employers for the past five years beginning with your current employer first. If this
time period includes times when you were a full-time student, indicate "student" and the name of the school(s) attended and
dates.
Client Questionnaire-Naturalization (citizenship)
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Employer Name
City & State
Position
Mo./Yr. Start
Mo./Yr. End
Please list your present and past membership in every organization or similar group since age 16. Include any professional
associations, clubs, foreign military service, etc :
Name and Address of Organization
Nature of Organization
Please state your height:
Ft.
Please state your weight:
Lbs.
Dates of Membership
Inches
Hair color:
Eye color:
Race/Origin:
(Select one):
White
Asian/Pacific Islander
Alaskan Native
Total Number of days you spent outside the U.S. in the past 5 years?
Client Questionnaire-Naturalization (citizenship)
Black
Unknown
Years
American Indian
Days
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How many trips of 24 hours or more have you taken outside the U.S, during the past 5 years?
Please list all of the trips you have taken outside the U.S. since becoming a lawful permanent resident:
Date left the U.S.
___/___/_____
___/___/_____
___/___/_____
___/___/_____
___/___/_____
___/___/_____
Date returned to U.S.
___/___/_____
___/___/_____
___/___/_____
___/___/_____
___/___/_____
___/___/_____
Countries to which you traveled
If you are male, have you ever registered for Selective Service?
If yes, please provide the following:
Selective Service No.:
Date registered:
Are either of your parents US Citizens?
Name:
No. of days outside the U.S.
Relation:
(Mother/Father)
If yes, please give the following details for the parent who is a US Citizen:
Date of Birth:
Birth Location:
Date became
U.S. Citizen
Please answer the following questions with "yes" or "no " If the answer to any of these questions is "yes," please use
additional paper to provide details.
Question:
Yes
1. Have you ever been arrested or charged with violating any law?
2. Have you ever been convicted of any crime?
3. Have you ever benefited from any pardon or expungement?
4. Have you ever received public aid or public assistance from any
source?
5. Have you ever been treated for a mental disorder, drug addiction, or
alcoholism?
6. Have you ever been a member of the Nazi or Communist Party?
7. Did you support the Nazi Government in Germany between 1933 and
1945?
8. Have you ever been charged with violating any law relating to a
cannabis or controlled substance violation?
9. Have you ever been ordered deported from the United States or ever
been stopped from entering the United States?
10. Have you ever assisted any other alien to enter the United States
illegally?
11. Have you ever sought a waiver of service in the U.S. Armed Forces?
12. Have you ever appeared before an immigration judge?
13. Have you ever claimed to be a U.S. Citizen?
14. Have you ever voted in any U.S. election?
15. Have you ever failed to file a U.S. Income Tax Return?
Client Questionnaire-Naturalization (citizenship)
No
Additional Information
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16. Have you ever lied or given false or misleading information to a U.S.
government official?
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