Form Templates:
1 Form 2202-L-A
U. S. DEPARTMENT OF LABOR
IMMIGRATION AND
NATURALIZATION SERVICE
2 Form 500 B
U.S. DEPARTMENT OF LABOR
IMMIGRATION SERVICE
3 Form TBD
Type
FORM 2202-L-A
Form Templates:
1 Form 2202-L-A
U. S. DEPARTMENT OF LABOR
IMMIGRATION AND
NATURALIZATION SERVICE
2 Form 500 B
U.S. DEPARTMENT OF LABOR
IMMIGRATION SERVICE
3 Form TBD
Type
ORIGINAL (To be retained by clerk)
No. ____________
UNITED STATES OF AMERICA
------------
DECLARATION OF INTENTION
(Invalid for all purposes seven years after
the date hereof)
______________________}
In the _______________________Court
______________________} ss:
of ____________ at ______________
I, _____________________________________________________________________
now residing at __________________________________________________________
occupation ________ aged ____ years, do declare on oath that my personal description is:
Sex ___________, color _________, complexion _________, color of eyes ___________
color of hair ______, height __ feet __ inches; weight ____ pounds; visible distinctive marks
______________________________________________________________________
race __________________________________; nationality _______________________
I was born in ___________________________, on ______________________________
I am _____ married. The name of my wife or husband is __________________________
we were married on _______________, at _________________________; she or he was
born at ______________________, on ___________________, entered the United States
at ________________, on _________________, for permanent residence therein, and now
resides at _______________ I have _____ children, and the name, date and place of birth,
and place of residence of each of said children are as follows: _______________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
I have ___ heretofore made a declaration of intention: Number _________on ____________
at _____________________________________________________________________
my last foreign residence was ________________________________________________
I emigrated to the United States of America from _________________________________
my lawful entry for permanent residence in the United States was at ___________________
under the name of _________________________, on ____________________________
on the vessel ____________________________________________________________
(If other than vessel, state manner of arrival)
I will, before being admitted to citizenship,
renounce forever all allegiance and fidelity to any foreign prince, potentate,
state, or sovereignty, and particularly, by name, to the prince, potentate,
state, or sovereignty of which I may be at the time of admission a citizen or
subject; I am not an anarchist; I am not a polygamist nor a believer in the
practice of polygamy; and it is my intention in good faith to become a citizen
of the United States of America and to reside permanently therein; and I certify
that the photograph affixed to the duplicate and triplicate hereof is a likeness
of me; SO HELP ME GOD.
[DO NOT ATTACH PHOTOGRAPH TO THIS COPY OF THE
DECLARATION]
____________________________________________
(Original signature of declarant without abbreviation, also alias, if used)
Subscribed and sworn to before me in the office of the Clerk of said
Court at _____________________ this ____ day of _____________
anno Domini 19 ____. Certification No. ________ from the Commis-
sioner of Immigration and Naturalization showing the lawful entry of the
declarant for permanent residence on the date stated above, has been
received by me. The photograph affixed to the duplicate and triplicate
hereof is a likeness of the declarant.
_________________________________________
[SEAL] Clerk of the __________________________ Court
By __________________________ , Deputy Clerk
Form 2202-L-A
U. S. DEPARTMENT OF LABOR
IMMIGRATION AND NATURALIZATION SERVICE
[Visitor number