Form N-470 (2010) Application To Preserve Residence For Naturalization Purposes Page 2
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1
2Part 3. Additional information.
1.
Give the date that you obtained lawful permanent resident status.
(mm/dd/yyyy)
2.
Since lawful entry as a permanent resident, have you resided in and been physically present in the United States for an
uninterrupted period of at least 1 year?
Yes
No
3. List all you absences from the United States since your admission as a lawful permanent resident. Begin with your most recent trip.
Date of Departure
Date of Return
Port of Entry Into
Purpose of Trip
(mm/dd/yyyy)
(mm/dd/yyyy)
the United States
4. Explain the position of employment that requires your absence from the United States and the intended length of employment.
5. Is the name you provided in Part 1 different from the name that appears on your Form I-551, Permanent
Yes
No
Resident Card?
If "Yes," note the information that is different. You must provide evidence showing the legal basis for the difference.
6. Since becoming a lawful permanent resident, 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?
Yes
No
7.
Are other family members who are lawful permanent residents intending to reside outside the United States
with you?
Yes
No
Give the following information about other family members who will reside outside the United States with you.
Name (Last/First/Middle)
Date of Birth
Relationship
A Number
(mm/dd/yyyy)
(if applicable)
Part 4. Signature.
Read the information on penalties in the instructions before completing this part.
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit sought.
Signature of Applicant
Daytime Phone Number (with area code)
E-Mail Address (if any)
Date (mm/dd/yyyy)
NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible
for the requested document and this application may be denied.
Part 5. Signature of person preparing form, if other than above.
(Sign below)
I declare that I prepared this application at the request of the applicant and it is based on all information of which I have knowledge.
Signature of Preparer
Print or Type Your Name
Firm Name and Address
Date (mm/dd/yyyy)
Daytime Phone Number (with area code)
E-Mail Address (if any)
Fax Number (if any)
Form N-470 (Rev. 01/06/2010) N Page 2
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