Form N-336 Request for Hearing on a Decision in Naturalization Proc

OMB No. 1615-0050: Expires 04/30/2012

Form N-336, Request for a Hearing on a
Decision in Naturalization Proceedings

Department of Homeland Security
U.S. Citizenship and Immigration Services

(Under Section 336 of the INA)

Print or type all your answers fully and accurately in black ink. Write “N/A” if an item is not applicable. Write “None” if the
answer is none. Failure to answer all of the questions may delay your Form N-336.

Part 1. Information About You, the Naturalization Applicant

Your A-Number:

-

A

1. Current Legal Name (do not provide a nickname)

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For USCIS Use Only

Family Name (last name)

Bar Code

Date Stamp

Given Name (first name)

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Middle Name (if applicable)

Remarks

2. Date of Birth (mm/dd/yyyy)

Re-Affirm
N-400 Denial

3. Home Address

Street Number and Name (do not provide a P.O. Box in this space unless it is
your ONLY address.)

Apartment Number

City

County

State

ZIP Code

Province (foreign address only)

Country (foreign address only)

Postal Code (foreign address only)

Re-Determine
N-400 Denial

4. Mailing Address

C/O (in care of name)

Apartment Number

Street Number and Name

Province (foreign address only)

5. Daytime Phone Number

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)

Mobile Phone Number (if any)

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ZIP Code

State

City

Country (foreign address only)

Postal Code (foreign address only)

Work Phone Number (if any)

Evening Phone Number

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)

6. E-Mail Address (if any)

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Form N-336 (Rev. 10/03/11) N

Part 2. Information About Form N-400 (Application for Naturalization)
Denial On Which You Are Requesting a Hearing
1. Form N-400 Receipt Number

2. Date of Form N-400
Denial Notice(mm/dd/yyyy)

A

-

-

3. USCIS Office That Issued Form N-400
Denial Notice

Part 3. Reason You Are Requesting a Hearing
Provide the reason(s) you are requesting a hearing on your denied Form N-400. If extra space is needed to provide an explanation,
attach an additional sheet(s) of paper. You must write your A-Number, the date, the question number, and sign the top of each
additional sheet(s).

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NOTE: Refer to Form N-336 Instructions, Page 1, Document Submission, for documents to submit with your Form N-336.

Form N-336 (Rev. 10/03/11) N Page 2

Part 4. Accommodations for Individuals With Disabilities and/or
Impairments

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A

Are you requesting an accommodation for the Form N-336 hearing because of a disability and/or
impairment? (see Part 4, Specific Form Instructions, in the Form N-336 instructions for some examples
of accommodations)

Yes

No

If you checked "Yes," check the box(es) below that apply:
I am deaf or hearing impaired and need a sign language interpreter who uses the following language (e.g., American Sign
Language (ASL)):

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I use a wheelchair.

I am blind or sight-impaired.

I will need another type of accommodation. Explain:

Part 5. Your Signature (USCIS will reject your Form N-336 if it is not signed.)

I certify, under penalty of perjury under the laws of the United States, that this request, and the evidence submitted with it, is all true
and correct. I authorize the release of any information that U.S. Citizenship and Immigration Services needs to determine eligibility
for naturalization.
Date (mm/dd/yyyy)

Your Signature

Part 6. Signature of Person Who Prepared This Form N-336 For You (if applicable)

I declare that I prepared Form N-336 at the request of the above person. The answers provided are based on information of which I have
personal knowledge or were provided to me by the above-named person in response to the questions contained on this Form N-336.
Preparer's Printed Name

Preparer's Signature

Preparer's Firm or Organization Name (if applicable)

Date (mm/dd/yyyy)

Preparer's Daytime Phone Number

(

)

Preparer's Address
Street Number and Name

City

State

ZIP Code

Province (foreign address only)

Country (foreign address only)

Postal Code (foreign address only)

Preparer's E-Mail Address (if any)

Preparer's Fax Number

(

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Form N-336 (Rev. 10/03/11) N Page 3