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

Request for a Hearing on a Decision in Naturalization
Proceedings

USCIS
Form N-336

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

OMB No. 1615-0050
Expires 01/31/2016

For USCIS Use Only
Barcode

Date Stamp

Remarks

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REPRODUCTION
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Re-Affirm N-400 Denial
To be completed by an
attorney or accredited
representative (if any).

Re-Determine N-400 Denial

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)

► START HERE - Type or print in black ink.
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-336.
Enter Your 9 Digit A-Number:

Part 1. Information About You, the Naturalization Applicant
1.

Current Legal Name (do not provide a nickname)
Family Name (Last Name)

2.

► A-

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 9. Additional Information.
Family Name (Last Name)

3.

Date of Birth (mm/dd/yyyy)

Given Name (First Name)

4.

Middle Name

USCIS Online Account Number (if any)
►

5.

Physical Address (do not provide a PO Box in this space unless it is your only address)
Street Number and Name
Apt. Ste. Flr. Number

City or Town

County

State

ZIP Code + 4
-

Province or Region
(foreign address only)

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Postal Code
(foreign address only)

Country
(foreign address only)

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► A-

Part 1. Information About You, the Naturalization Applicant
(continued)
6.

Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

County

ZIP Code + 4

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-

Province or Region
(foreign address only)

7.

Postal Code
(foreign address only)

Country
(foreign address only)

Contact Information
A. Daytime Telephone Number

B. Work Telephone Number (if any)

C. Evening Telephone Number

D. Mobile Telephone Number (if any)

E. Email Address (if any)

Part 2. Information About Form N-400 Denial On Which You (the Naturalization Applicant) Are
Requesting a Hearing
1.

Form N-400 Receipt
Number

2.

3.

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

USCIS Office That Issued Form N-400
Denial Notice

Part 3. Biographic Information
1.

Ethnicity (Select only one box)
Hispanic or Latino

2.

Not Hispanic or Latino

Race (Select all applicable boxes)
White

Asian

Black or African
American

3.

Height

Feet

4.

Weight

Pounds

5.

Eye Color (Select only one box)
Black

6.

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Inches

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No
hair)

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Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/
Other
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Part 4. Reason You Are Requesting a Hearing

► A-

Provide the reasons you are requesting a hearing on your denied Form N-400. If you need extra space to complete this section, use the
space provided in Part 9. Additional Information.
NOTE: Refer to the What Evidence Must You Submit section of Form N-336 Instructions for documents to submit with your Form
N-336.

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Form N-336 01/07/13 N

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Part 5. Accommodations for Individuals With Disabilities and/or
Impairments

► A-

NOTE: Read the information in the Form N-336 Instructions before completing this part.
1.

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

Yes

No

If you answered "Yes" to Item Number 1., select any applicable box.
A.

B.

C.

I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language
interpreter, indicate for which language (for example, American Sign Language).)

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

I have another type of disability and/or impairment. (Describe the nature of your disability and/or impairment and the
accommodation you are requesting.)

Part 6. Naturalization Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form N-336 Instructions before completing this part.

Naturalization Applicant's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Naturalization Applicant's Statement Regarding the Interpreter
A.
B.

I can read and understand English, and I have read and understand every question and instruction on this request
and my answer to every question.

The interpreter named in Part 7. read to me every question and instruction on this request and my answer to
every question in
, a language in which I am fluent, and I
understood everything.

2.

Naturalization Applicant's Statement Regarding the Preparer
At my request, the preparer named in Part 8.,

,

prepared this request for me based only upon information I provided or authorized.

Naturalization Applicant's Contact Information
3.

Naturalization Applicant's Daytime Telephone Number

5.

Naturalization Applicant's Email Address (if any)

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4.

Naturalization Applicant's Mobile Telephone Number (if any)

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► A-

Part 6. Naturalization Applicant's Statement, Contact Information,
Certification, and Signature (continued)
Naturalization 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 request, 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 understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:

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1) I reviewed and provided or authorized all of the information in my request;

2) I understood all of the information contained in, and submitted with, my request; and
3) All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that I provided or authorized all of the information in my request, I understand all of the
information contained in, and submitted with, my request, and that all of this information is complete, true, and correct.

Naturalization Applicant's Signature
6.

Naturalization Applicant's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL NATURALIZATION APPLICANTS: If you do not completely fill out this request or fail to submit required
documents listed in the Instructions, USCIS may deny your request.

Part 7. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

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Postal Code

ZIP Code + 4
-

Country

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Part 7. Interpreter's Contact Information, Certification, and Signature

► A-

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

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I certify, under penalty of perjury, that:

, which is the same language specified in Part 6.,
I am fluent in English and
Item B., in Item Number 1.; and I have read to this naturalization applicant in the identified language every question and instruction
on this request and his or her answer to every question. The naturalization applicant informed me that he or she understands every
instruction, question, and answer on the request, including the Naturalization Applicant's Certification, and has verified the
accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Naturalization Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form N-336 01/07/13 N

Postal Code

ZIP Code + 4
-

Country

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Part 8. Contact Information, Declaration, and Signature of the Person
Preparing this Request, if Other Than the Naturalization Applicant
(continued)

► A-

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

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Preparer's Statement
7.

A.
B.

I am not an attorney or accredited representative but have prepared this request on behalf of the naturalization
applicant and with the naturalization applicant's consent.
I am an attorney or accredited representative and my representation of the naturalization applicant in this case
extends
does not extend beyond the preparation of this request.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation
of this request, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this request.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this request at the request of the naturalization applicant. The
naturalization applicant then reviewed this completed request and informed me that he or she understands all of the information
contained in, and submitted with, his or her request, including the Naturalization Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this request based only on information that the naturalization applicant
provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

Form N-336 01/07/13 N

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Part 9. Additional Information
If you need extra space to provide any additional information within this request, 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 request 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.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

Middle Name

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A. Page Number

D.

Given Name (First Name)

A. Page Number

D.

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