GETSON & SCHATZ, P.C.

230 S. Broad Street, Suite 1001

Philadelphia, PA 19102
(215) 520-4000
Fax (215) 520-4001
E-Mail: Click4law@aol.com

NATURALIZATION QUESTIONNAIRE
Part 1. Name Alien Number ________________________
Current Legal Name: (last) _________________ (first) ______________________ (middle)______________
Name Exactly as it appears on Permanent Resident Card: ________________________________________
If you have ever used any other names since birth, including maiden name, nicknames, and aliases, please
provide them below:
_______________________________________________________________________________________
Do you want to legally change your name? ___yes ___no
If yes, print the new name you would like to use ________________________________________________

Part 2. Eligibility/Information about you

Social Security Number: _______-______-_______ Date of Birth: ____(mm)/____(dd)/_____(yyyy)
Date you became Permanent Resident: _____(mm)/_____(dd)/_____ (yyyy) Country of Birth
______________________
Country of Citizenship or Nationality ______________________

Do you need accommodations because your are deaf or hard of hearing, use a wheelchair or other device that
assists with mobility, blind or low vision, or any other type of accommodation. ___yes ___no
If yes, why? _____________________________________________________________________________

Do you have a physical or developmental disability or mental impairment that prevents you from demonstrating
your knowledge and understanding of the English language and/or civics requirements for naturalization:
___yes ___no

Part 3. Address and Telephone

Current Address: ____________________________ Mailing Address: ________________________
_____________________________ (if different) ________________________
_____________________________ ________________________
Telephone: (day) ___________________________ (evening) ______________________________
(work) __________________________ (cell) __________________________________
E-Mail Address: ______________________________________________________________________

Part 4. Residence
Please provide ALL places you have resided for the past 5 years in the following table, starting with present
address and working backward in time.

1. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

2. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

3. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

4. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

5. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

6. Street Address City/County State

Zip Code
Country Resided From Resided To
Month/Day/Year Month/Day/Year

Part 5. Information about Parents

Were your parents married before your 18th birthday? _____yes _____no
Is your mother a U.S. Citizen? ____yes ____no
If yes, current Legal Name of your U.S. Citizen Mother: ____________________________________________
Country of Birth: _______________________ Date of Birth: ________________________
Is your father a U.S. Citizen? ____yes ____no
If yes, current Legal Name of your U.S. Citizen Father: ____________________________________________
Country of Birth: _______________________ Date of Birth: ________________________

Part 6. Background Information

Gender: ____Male _____Female

Height: ____feet _____inches
Weight: _______pounds
Race: White_____, Asian_______, Black/African American________, American Indian or
Alaska Native_________, Native Hawaiian or Other Pacific Islander_____________
Hair Color: _______________
Eye Color: _______________

Part 7. Employment/Schools

List where you have worked or attended school full time or part time during the last 5 years. Include all
military, police, and/or intelligence service. If you worked for yourself write “self-employed”. If you were
unemployed, write “unemployed”. Start with the present and work backward in time:

1. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

2. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

3. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

4. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year
 5. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

6. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

7. Name of School/Employer Occupation

Street Address City State

Zip Code
Country From To
Month/Day/Year Month/Day/Year

Part 8. Time outside the U.S.

How many days did you spend outside the U.S. during the past 5 yrs? ______ Days
How many trips of 24 hrs. or longer have you taken outside the U.S. during the past 5 yrs? ______ Trips
List below all the trips of 24 hrs. or longer that you have taken outside the U.S. during the last 5 years. Begin
with
Your most recent trip and work backwards.

Date you left Date you returned Trip last 6 Countries Travelled # of Days Out of
Month/Day/Year Month/Day/Year months or more? U.S.

Part 9. Marital History

What is your current marital status
Single, never married_______, married________, separated________, divorced_________,
widowed_________, marriage annulled_________
If you are married is your spouse a current member of the U.S. Armed Forces _______yes, ________no
How many times have you been married? (including annulled marriages and marriage(s) to the same person)
______ If never go to Part 8.
If Married, give the following information:
Legal name of current spouse: (last) ________________ (first) _______________ (middle) ______________
Previous legal name of current spouse (last) ________________ (first) _______________ (middle)
______________
Has your spouse ever used any other names, including nicknames, aliases, maiden name? If yes, please
provide them: ____________________________________________________________________________
Date of Birth: ____(mm)/____(dd)/_____(yyyy) Date Married: ____(mm)/____(dd)/_____(yyyy) Spouse’s
social security #________________
Current’s Spouse’s Present Home Address (include county if in US or Province/Region if overseas)
__________________________________________________________________
Current Spouse’s Present Employer:
_____________________________________________________________
Is Spouse a USC? ___yes ___no If yes when? ____At Birth ____Other - Date of
Citizenship____(mm)/____(dd)/_____(yyyy)
If not a USC: Spouse’s Country of Citizenship___________________ Spouse’s “A”
Number._______________
Spouse’s Immigration Status: _____Lawful Permanent Residence____Other (Identify status_____________)

How many times has your current spouse been married (including annulled marriages and marriage(s) to the
same person) __________
If current spouse was previously married, please provide the following information about his/her prior
spouse (if more than one previous spouse, please provide the following information on a separate
sheet of paper for each previous spouse):
Prior Spouse’s name: (last) ___________________________ (first) __________________________
Full Middle name: ____________________________ Date of Birth: ____(mm)/____(dd)/_____(yyyy)
Country of Birth: ____________________ Country of Citizenship or Nationality: ______________________
Date of Marriage: ____(mm)/____(dd)/_____(yyyy) Date Marriage ended: ____(mm)/____(dd)/_____(yyyy)
How Marriage Ended: Annulled______, Divorce ____Spouse Died _______ Other
(Explain)___________________
Immigration Status of your present spouse prior spouse at the time marriage ended: Permanent Resident
________ U.S. Citizen _________ Other _____ (Explain_______________________)

If you were previously married provide the following information (if more than one previous spouse,
please provide the following information on a separate sheet of paper for each of your previous
spouses):
Prior Spouse’s name: (last) ___________________________ (first) __________________________
Full Middle name: ____________________________ Date of Birth: ____(mm)/____(dd)/_____(yyyy)
Country of Birth: ____________________ Country of Citizenship or Nationality: ______________________
Date of Marriage: ____(mm)/____(dd)/_____(yyyy) Date Marriage ended: ____(mm)/____(dd)/_____(yyyy)
How Marriage Ended: Annulled______ Divorce ____ Spouse Died _______ Other
(Explain)___________________
Immigration Status of your prior spouse at the time your marriage ended: Permanent Resident ________
U.S. Citizen _________ Other ___________ (Explain________________)

Part 10. Children Information Total Number of Children: ___________

ALL children should be indicated: A. Children who are alive, deceased, missing; B. Children born in
the United States or other countries; C. Children under 18 years of age or older; D. Children who are
currently married or unmarried; E. Children living with you or elsewhere; F. Current stepchildren; G.
Legally adopted children and H. Children born when you were not married. (If more than four
children, please provide this information on a separate piece of paper)

1. Last Name First Name Middle Name

A# Date of Birth Country of Birth

Month/Day/Year

Current Place of Residence:

Street Name and Number City and State Country
 Child’s Relationship to you: Biological Child
(Circle One) Stepchild
Legally Adopted

Part 10. Children Information (Cont.)

2. Last Name First Name Middle Name

A# Date of Birth Country of Birth

Month/Day/Year

Current Place of Residence:

Street Name and Number City and State Country

Child’s Relationship to you: Biological Child

(Circle One) Stepchild
Legally Adopted

3. Last Name First Name Middle Name

A# Date of Birth Country of Birth

Month/Day/Year

Current Place of Residence:

Street Name and Number City and State Country

Child’s Relationship to you: Biological Child

(Circle One) Stepchild
Legally Adopted

4. Last Name First Name Middle Name

A# Date of Birth Country of Birth

Month/Day/Year
 Current Place of Residence:
Street Name and Number City and State Country

Child’s Relationship to you: Biological Child

(Circle One) Stepchild
Legally Adopted

Part 11. Additional Questions

(If you answer YES to any of the following questions, attach a written explanation on separate sheet of
paper and provide any documentation to support your answer)

Have you EVER claimed to be a United States Citizen (in writing or any other way) ___yes ___no
Have you EVER registered to vote in any Federal, state, or local election in the US ___yes ___no
Have you EVER voted in any Federal, state, or local election in the US ___yes ___no
Do you now have, or did you EVER have, a hereditary title or an order of nobility in any foreign
Country ___yes ___no
Have you EVER been declared legally incompetent or been confined to a mental institution ___yes ___no
Do you owe any overdue Federal, state, or local taxes ___yes ___no
Since becoming a lawful Permanent Resident, have you EVER not filed a Federal,
state or local tax return ___yes ___no
If “Yes”, did you consider yourself to be a non-U.S. Resident? ___yes ___no
Have you EVER called yourself a “non-U.S. Resident” on a Federal, Local, or State
tax return since you became a Permanent Resident ___yes ___no

Have you EVER been a member of, involved in, or in any way associated with any organization,
association, fund, foundation, party, club, society, or similar group in the U.S. or any other location
in the world ___yes ___no
If you answered “YES,” list the name of each group below. If additional space is needed use separate sheet.

Name of Group Purpose of the Group Dates of Membership

From To
(mm/dd/yyyy) (mm/dd/yyyy)
Have you EVER been a member of or in any way associated (directly or indirectly) with:
The Communist Party ___yes ___no
Any other totalitarian Party ___yes ___no
A terrorist organization ___yes ___no

Have you EVER advocated (directly or indirectly) the overthrow of any government by
force or violence? ___yes ___no
Have you EVER persecuted (directly or indirectly) any person because of race, religion,
national origin, membership in a particular social group, or political opinion ___yes ___no
Between March 23, 1933, and May 8, 1945, did you work for or associate in any way
(directly or indirectly) with:
 The Nazi government of Germany ___yes ___no
 Any government in any area (1) occupied by, (2) allied with, or (3) established with the
help of the Nazi government of Germany ___yes ___no
 Any German, Nazi, or S.S. military unit, paramilitary unit, self-defense unit, vigilante
unit, citizen unit, police unit, government agency or office, extermination camp,
concentration camp, prisoner of war camp, prison, labor camp, or transit camp ___yes ___no

Were you EVER involved in any way with any of the following:
Genocide? ___yes ___no
Torture? ___yes ___no
Killing, or trying to kill, someone? ___yes ___no
Badly hurting, or trying to hurt, a person on purpose? ___yes ___no
Forcing, or trying to force, someone to have any kind of sexual
contact or relations? ___yes ___no
No letting someone practice his or her religion? ___yes ___no

Were you EVER a member of, or did you EVER serve in, help, or otherwise participate in, any of the following
groups:

Military unit? ___yes ___no

Paramilitary unit? (acting like military but not official military) ___yes ___no
Police unit? ___yes___no
Self-defense unit? ___yes ___no
 Vigilante unit? (acting like police but not official police) ___yes ___no
Rebel group? ___yes___no
Guerrilla group? (using weapons against/attacking others) ___yes ___no
Militia? (an unofficial army) ___yes ___no
Insurgent organization? (use weapons against/fight government) ___yes ___no

Were you EVER a worker, volunteer, or soldier, or did you otherwise EVER serve in any of the following:
Prison or jail ___yes ___no
Prison camp ___yes ___no
Detention facility? (place where people forced to stay) ___yes ___no
Labor camp? (place where people forced to work) ___yes ___no
Any other place where people were force to stay? ___yes ___no

Were you EVER a part of any group, or did you EVER help any group, unit or organization that used a weapon
against any person, or threatened to do so? ___yes
___no
If “Yes,” when you were part of this group, or when you helped this group, did you ever use a
weapon
against another person? ___yes ___no
If “Yes,” when you were part of this group, or when you helped this
group, did you ever tellbanother person that you would use a weapon
against that person? ___yes ___no

Did you EVER sell, give, or provide weapons to any person, or help another person sell, give, or provide
weapons to any person?
___yes ___no
If “Yes,” did you know this person was going to use the weapon against another
person? ___yes ___no
If “Yes,” did you know that this person was going to sell or give the weapons to someone who
was going to use them against another person? ___yes ___no

Did you EVER receive any type of military, paramilitary ( a group of people who act like a military group but
are not part of the official military), or weapons training? ___yes
___no

Did you EVER recruit (ask), enlist (sign up), conscript (require), or use any person under age 15 to serve in
or help am armed force or group? ___yes
___no

Did you EVER use any person under the age of 15 to do anything that helped or supported people in
combat?
___yes ___no

If any of the following questions apply to you, you must answer “YES” even if your records have been
sealed, expunged, or otherwise cleared. You MUST disclose this information even if anyone, including
a judge, law enforcement officer, or attorney, told you that it no longer constitutes a record or told you
that you do not have to disclose the information.

Have you EVER committed, assisted in committing or attempted to commit, a crime or offense
for which you were NOT arrested ___yes ___no
Have you EVER been arrested, cited, or detained by any law enforcement officer for any reason
(including ANY and ALL immigration officials or the U.S. Armed Forces) ___yes ___no
Have you EVER talked to a police officer or any law enforcement officer for any reason
even if you were not actually charged and/or convicted of a crime ___yes ___no
Have you EVER seen a judge for any reason ___yes ___no
Have you EVER been charged with committing, attempting to commit, or assisting in committing a
crime or offense ___yes ___no
Have you EVER been convicted of any crime or offense ___yes ___no
Have you EVER been placed in an alternative sentencing or rehabilitative program
(EXAMPLE: diversion, deferred prosecution, withheld adjudication, deferred adjudication) ___yes ___no
Have you EVER received a suspended sentence, been placed on probation, or been paroled ___yes ___no
If “YES”, have you completed the probation or parole? ___yes ___no
Have you EVER been in jail or prison? ___yes ___no
If “YES” how long were you in jail or prison ? Years: ____ Months: _____ Days:______

If you answered “YES” to ANY OF THE PREVIOUS SEVEN QUESTIONS, complete the following table. If you
need more space use an additional sheet(s) of paper and provide any evidence to support your answer.
Please note that your will need to obtain and provide us CERTIFIED COPY OF THE FINAL DISPOSITION
FOR ALL OF YOUR ARRESTS BEARING THE SEAL OF THE COURT.

Why were you Date arrested, cited, Where were you Outcome or
arrested, cited, detained, or arrested, cited, disposition of the
detained, or charged. detained, or arrest, citation,
charged? (mm/dd/yyyy) charged?(City, detention or charge
State, Country) (no charges filed,
charges dismissed,
jail, probation, etc.)
FOLLOWING QUESTIONS IF “YES” ATTACH WRITTEN EXPLANATION OR DOCUMENTATION
HAVE YOU EVER:
Been a habitual drunkard ___yes ___no
Been a prostitute, or procured anyone for prostitution ___yes ___no
Sold or smuggled controlled substances, illegal drugs or narcotics ___yes ___no
Been married to more than one person at the same time ___yes ___no
Married someone in order to obtain an immigration benefit ___yes ___no
Helped anyone to enter or try to enter the United States illegally ___yes ___no
Gambled illegally or received income from illegal gambling ___yes ___no
Failed to support your dependents or to pay alimony ___yes ___no
Made any misrepresentation to obtain any public benefit in the U.S. ___yes ___no
Have you EVER given any U.S. Government Official(s) any information or documentation
that was false, fraudulent or misleading ___yes ___no
Have you EVER lied to any U.S. government official to gain entry or admission into the U.S
or to gain immigration benefits while in the United States . ___yes ___no
Have you EVER been removed, excluded, or deported from the U.S. ___yes ___no
Have you EVER been ordered removed, excluded, or deported from the U.S. ___yes ___no
Have you EVER been placed in removal, exclusion, rescission, or deportation proceedings? ___yes ___no
Are removal, exclusion, rescission or deportation proceedings (including administratively
closed proceedings) currently pending against you ___yes ___no
Have you EVER served in the US Armed Forces ___yes ___no
Are you CURRENTLY a member of the U.S. Armed Forces ___yes ___no
If you are CURRENTLY a member of the U.S. Armed Forces, are you scheduled to deploy overseas,
including to a vessel, within the next 3 months? ___yes ___no
If you are CURRENTLY in the U.S. Armed Forces, are you currently stationed overseas ___yes ___no
Have you EVER been court-martialed, administratively separated, or disciplined, or
have you received an other than honorable discharge, while in the U.S. Armed Forces ___yes ___no
Have you ever been discharged from training or service in the U.S. Armed Forces because
you were an alien ___yes ___no
Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces ___yes ___no
Have you EVER applied for any kind of exemption from military service in the U.S.
Armed Forces ___yes ___no

Have you EVER deserted from the U.S. Armed Forces: ___yes ___no
Are you a male who lived in the US at any time between your 18 and 26 birthdays in any status except as a
th th

lawful nonimmigrant ___yes ___no

If you answered “YES,” provide the information below
Date Registered (Month/Day/Year) _____/____/_________ Selective Service No.______________________
If you answered “YES,” but did NOT register with the Selective Service System and are still under 26 years of
age, you must register before you apply for naturalization, so that you can complete the information below:
If you answered “YES,” but did NOT register with the Selective Service System and you are now 26 years or
older, attach a statement explaining why you did not register.
IF YOU ANSWER ANY OF THE FOLLOWING QUESTIONS “NO”, ATTACH A WRITTEN EXPLANATION AS
TO WHY AND DOCUMENTATION TO SUPPORT YOUR RESPONSE
Do you support the Constitution and form of government of the US ___yes ___no
Do you understand the full Oath of Allegiance to the US ___yes
___no
Are you willing to take the full Oath of Allegiance to the US ___yes
___no
If the law requires it, are you willing to bear arms on behalf of the US ___yes
___no
If the law requires it, are you willing to perform noncombatant services in the US Armed Forces ___yes
___no
If the law requires it, are you willing to perform work of national importance under civilian direction ___yes
___no