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United States Citizenship Attestation Form

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United States Citizenship Attestation Form

For the purpose of complying with Neb. Rev. Stat. §§ 4-108 through 4-114, I attest as

follows:

I am a citizen of the United States.

— OR —

I am a qualified alien under the federal Immigration and Nationality Act. In addition to

this Form, I have included a current and legible copy of the front and back of one or

more of the available USCIS forms, (listed below), required for verification.

I-327 (Reentry Permit)

I-551 (Permanent Resident Card)

I-571 (Refugee Travel Document)

I-766 (Employment Authorization Card)

Certificate of Citizenship

Naturalization Certificate

Machine Readable Immigrant Visa (with Temporary I-551 Language)

Temporary I-551 Stamp (on passport or I-94)

I-94 (Arrival/Departure Record)

Unexpired Foreign Passport (must include an I-94)

I-20 (Certificate of Eligibility for Nonimmigrant (F-1) Student Status

DS2019 (Certificate of Eligibility for Exchange Visitor (J-1) Status

I hereby attest that my response and the information provided on this form and any

related application for public benefits are true, complete, and accurate and I

understand that this information may be used to verify my lawful presence in the

United States.

Print Name ____________________________________________________________

(First, Middle, Last)

Signature _____________________________________________________________

Individual NMLS ID # _______________________ Date ______________________

Revised 7/2012

United States Citizenship Attestation Form

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