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 TRIPLICATE

(To be given to declarant when originally issued; to be made a part of the petition for naturalization when petition is filed; and to be retained as a part of the petition in the records of the court)

In the Court

of at

(1) My full, true, and correct name is

(2) My present place of residence is

(3) My occupation is (4) I am  years old. (5) I was born on

in (6) My personal description is as follows: Sex

color, complexion , color of eyes , color of hair , height feet  inches, weight  pounds,

visible distinctive marks, race , present nationality

(7) I am married; the name of my wife or husband is ; we were married on

at ; he or she was born at

on ; and entered the United States at

on for permanent residence in the United States, and now resides at

(8) I have children; and the name, sex, date and place of birth, and present place of residence of each of said children who is living, are as follows:

(9) My last place of foreign residence was (10) I emigrated to the United States from

(11) My lawful entry for permanent residence in the United States was

at under the name of

on, on the

(12) Since my last lawful entry for permanent residence I have been absent from the United States, for a period or periods of 6 months or longer, as follows:

(13) I have heretofore made declaration of intention: No., on  at

in the

(14) It is my intention in good faith to become a citizen of the United States and to reside permanently therein. (15) I will, before being admitted to citizenship, renounce absolutely and forever all allegiance and fidelity to any foreign prince, potentate, state, or sovereignty of whom or which at the time of admission to citizenship I may be a subject or citizen. (16) I am not an anarchist; nor a believer in the unlawful damage, injury, or destruction of property, or sabotage; nor a disbeliever in or opposed to organized government; nor a member or affiliated with any organization or body of persons teaching disbelief in or opposition to organized government. (17) I certify that the photograph affixed to the duplicate and triplicate hereof is a likeness of me and was signed by me.

I do swear (affirm) that the statements I have made and the intentions I have expressed in this declaration of intention subscribed by me are true to the best of my knowledge and belief: SO HELP ME GOD.



Yul brynner immigration signature.jpg Subscribed and sworn to (affirmed) before me in the form of oath shown above in the office of the Clerk of said Court, at this  day of, anno Domini 19, I hereby certify that Certification No. from the Commissioner of Immigration and Naturalization, showing the lawful entry for permanent residence of the declarant above named on the date stated in this declaration of intention, has been received by me, and that the photograph affixed to the duplicate and triplicate hereof is a likeness of the declarant.

Clerk of the

By Yul brynner immigration signoff.jpg

e16-19110-1 U. S. GOVERNMENT PRINTING OFFICE