Form I-777 - Application For Replacement Of Northern Mariana Card Page 2
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1
2Part 3.
Additional Information
1. List all absences from the Commonwealth of the Northern Mariana Islands or the United States (List absences from the
present to the last)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Present
Present
2. At what address(es) have you lived for the last ten years? (List present address first)
From
To
Street Address (Number and Name)
City, State
(mm/dd/yyyy)
(mm/dd/yyyy)
present
Part 4. Signature
(Read the information on penalties in the instructions before completing this part)
I certify, under penalty of perjury of the laws of the United States of America, that my application and the evidence submitted with it
is all true and correct. I authorize the release of any information from my records that U.S.Citizenship and Immigration Services needs
to determine my eligibility for the benefit I am seeking.
Date (mm/dd/yyyy)
Signature
Daytime Phone Number (with area code)
NOTE: If you do not completely fill out this form or fail to submit the required documents listed in the instructions, you may not
be found eligible for the requested document, and this application may be denied.
Part 5.
Signature of Person Preparing Form, If Other than Above
(Sign below)
I declare that I prepared this application at the request of the person named above, and it is based on all information of which I have
knowledge.
Signature
Print or Type Your Name
Date (mm/dd/yyyy)
Firm Name and Address
E-Mail
Fax Number
Daytime Phone Number (with area code)
Form I-777 (Rev. 11/19/10) Y Page 2
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