Citizenship Certification - 2016-2017
ADVERTISEMENT
1Return Information to: CSC START Office
1000 Main Street, Chadron NE 69337
Phone: (308) 432-6060
Original form MUST be mailed!
2016-2017 Citizenship Certification
______________________________________________________
_____________________________
Student’s Last Name
Student’s First Name
Student’s M.I.
Student’s NUID or Social Security #
______________________________________________________
_____________________________
Student’s Street Address (include apt. no.)
Student’s Date of Birth
______________________________________________________
_____________________________
Student’s Email Address
City
State
Zip Code
______________________________________________________
_____________________________
Student’s Home Phone Number (include area code)
Student’s Alternate or Cell Phone Number
To verify your citizenship, you must provide:
(a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the notary statement below,
such as but not limited to a driver’s license, other state-issued ID, or passport;
(b) A copy of the valid government-issued Citizenship Document such as Birth Certificate, or a current U.S.
Passport. Additional acceptable documents are: Form FS-240, Form FS-545 Form DS-1350, Certificate of Citizenship
forms N-560 or N561, or Certificate of Naturalization forms N-550 or N-570.
(c) The original notarized Citizenship Certification provided below.
I certify that I, __________________________________, am the individual signing this statement. I am providing a
(Student’s Full Name)
copy of my original documents along with a copy of a valid government-issued Photo ID. I certify that the attached
documents and government-issued Photo ID are true, exact, and complete copies of the originals issued to me.
Proof of Citizenship Document
Valid Government-Issued Photo ID
Type:______________________________
Type:______________________________
Expiration Date:_____________________
Expiration Date:_____________________
Issuing Authority:____________________
WARNING: If you purposely give false or misleading information you may be fined, be sentenced to jail or both.
STUDENT SIGNATURE: ________________________________ DATE: __________________
Notary’s Certificate of Acknowledgement
State of _______________________ City/County of _____________________On____________________, before me,
(Date)
___________________________________, personally appeared, ___________________________________, and
(Notary’s name)
(Printed name of signer)
provided to me on basis of satisfactory evidence of identification _______________________________________ to be
(Type of government-issued photo ID provided)
the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
(seal)
________________________________________
(Notary signature)
My commission expires on __________________
(Date)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business