
Form N-648 Edition 09/25/24
Page 4 of 5
Part 5. Interpreter Information and Certification
Interpreter's Contact Information
Interpreter's Daytime Telephone Number3.
Interpreter's Email Address (if any)5.
Interpreter's Mobile Telephone Number (if any)4.
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Interpreter's Signature (not required for telephonic interpretations)6. Date of Signature (mm/dd/yyyy)
Interpreter's Certification
I further certify that I have accurately and completely interpreted all communications between the certifying medical professional and
I certify that I am fluent in English and the following language,
the applicant that occurred on
.
, the date(s) of the examination(s) that form the basis of this certification.
Part 6. Applicant's (Patient's) Attestation/Release of Information
I,1. (Applicant's Name),
authorize (the Licensed medical doctor,
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 medical
disability exception.
doctor of osteopathy, or clinical psychologist completing this form) to release to U.S. Citizenship and Immigration Services
(USCIS) 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 certifying 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
(Licensed medical doctor, doctor of osteopathy, or clinical psychologist) and was then
Applicant Signature (or mark if applicant is unable to sign)2.
Date of Signature (mm/dd/yyyy)
2.
Family Name (Last Name)
Given Name (First Name)
Interpreter's Name
Middle Name (if applicable)
If in-person interpretation services were used during the medical examination, the interpreter must fill out this section, sign, and date
the certification. If telephonic interpretation services were used during the medical examination, the certifying medical professional
must complete all items in this section, except Item Number 6.
Was a telephonic or video facilitated interpreter used during the examination of the applicant?1.
Yes No