Exhibit 3-5: Sample Citizenship Declaration

INSTRUCTIONS: Complete this Declaration for each member of the household listed on the Family Summary Sheet

LAST NAME

FIRST NAME RELATIONSHIP TO DATE OF HEAD OF HOUSEHOLD SEX BIRTH _____________ SOCIAL ALIEN SECURITY NO. REGISTRATION NO.

ADMISSION NUMBER__________________________if applicable (this is an 11-digit number found on DHS Form I-94, Departure Record )

NATIONALITY (Enter the foreign nation or country to which you owe legal allegiance. This is normally but not always the country of birth.)

SAVE VERIFICATION NO. (to be entered by owner if and when received)

INSTRUCTIONS: Complete the Declaration below by printing or by typing the person's first name, middle initial, and last name in the space provided. Then review the blocks shown below and complete either block number 1, 2, or 3: