Form N-648 Edition 07/23/20
Page 8 of 9
Part 4. Interpreter's Certification (continued)
Interpreter's Signature 7. Date of Signature (mm/dd/yyyy)
I further certify that I have accurately and completely interpreted all communications between the medical professional and the
I certify that I am fluent in English and the following language,
applicant that occurred on
, the dates of the examinations that form the basis of this certification.
Certification for Telephonic Interpreter (to be completed by the medical professional)
Was a telephonic interpreter used during the examination of the applicant?8.
Yes (go to question 9.) No
If you answered yes, did you ask the interpreter to affirm that he or she speaks fluent English and the applicant's language and
that he or she will accurately and completely interpret all communications between you and the applicant?
If yes, did the interpreter answer in the affirmative?10.
Part 5. Applicant's (Patient's) Attestation/Release of Information
I,1. (Applicant's Name),
authorize (Licensed medical doctor,
doctor of osteopathy, or clinical psychologist) to release to U.S. Citizenship and Immigration Services all relevant physical and
mental health information related to my medical status for the purpose of applying for an exception from the English language
and U.S. civics requirements for naturalization. I certify under penalty of perjury, pursuant to 28 U.S.C. section 1746, that the
information I provided to the medical professional is true and correct. I certify under penalty of perjury, pursuant to 28 U.S.C.
section 1746, that I have attended an appointment with
medical doctor, doctor of osteopathy, or clinical psychologist) and was then diagnosed by him or her. I am aware that the
knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under 8
U.S.C. section 1324c and INA section 274C. I understand that if this form is not completely filled out or if I fail to submit any
required documentation, I may be found ineligible for the requested disability exception.
Applicant or Applicant's Authorized Representative's Signature2. Date of Signature (mm/dd/yyyy)
Part 6. Medical Professional's Certification
Complete the following if you did not use an interpreter to communicate with the applicant during the examinations that form the
basis of this Form N-648.
I did not use an interpreter during my examinations of this applicant because:1.
I am fluent in English and
, the language spoken by this
This applicant speaks English.