Download:
pdf |
pdfOMB No. 1615-0059; Expires 09/30/2012
N-644, Application for
Posthumous Citizenship
Department of Homeland Security
U.S. Citizenship and Immigration Services
For USCIS Only
Fee Stamp
Part 1.
Information About the Applicant (To be completed by the applicant only)
1. Name (Last/First/Middle)
8. Your Relationship to Decedent at Time of His/Her Death
(Check one)
Next-of-Kin
2. Address (Street Name and Number)
(Town/City, State/Country, Zip/Postal Code)
3. If Abroad, City/Country of Nearest U.S. Embassy or Consulate
4. Date of Birth
6. Total Number of Authorization Affidavits Attached (See instructions)
(
Spouse
b.
Parent
c.
Son/Daughter
d.
Brother/Sister
Representative
5. A-Number, if applicable
7. Telephone Number (Include Area/Country Code)
a.
e.
Executor or Administrator of Decedent's Estate
f.
Guardian, Conservator, or Committee of Decedent's
Next-of-Kin
g.
VA Recognized Service Organization (Name below)
(Name of Service Organization)
9. E-mail Address
)
B. Information About the Decedent
1. Name Used During Active Service (Last/First/Middle)
7.
Immigration Status at Time of Death (Permanent Resident,
Student, Visitor, etc.)
8.
A-Number or Other USCIS File Number
9.
U.S. Social Security Number (If any)
2. Other Names Used
3. Date of Birth (mm/dd/yyyy) 4. Place of Birth (City/State/Country)
5. Date of Death (mm/dd/yyyy) 6. Place of Death (City/State/Country)
Form N-644 (08/01/12) Y
B. Information About the Decedent (Continued)
10. Father's Full Name
11. Mother's Maiden Name
Living
B.
Deceased
Name (Last/First/Middle)
Living
Deceased
Date of Birth (mm/dd/yyyy)
Living
Deceased
C.
Living
Deceased
Name (Last/First/Middle)
12. Marital Status at Time of Death
a. Married
c. Widowed
b. Divorced
d. Single
D.
Living
Date of Birth (mm/dd/yyyy)
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
13. Military Service Serial Number (If different from Social Security #)
E.
14. Date Entered Active Duty Service (mm/dd/yyyy)
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
15. Place Entered Active Duty Service (City/State/Country)
24. Total Number of Brothers and Sisters (If none, write "None")
16. Date Released From Active Duty Service (mm/dd/yyyy)
25. Complete the Following for Each Brother and Sister
17. Branch of Service
18. Type of Discharge
A.
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
20. Retired From Military?
19. Military Rank at Time of
Discharge
Yes
No
B.
Living
21. VA Claim Number (If any)
Name (Last/First/Middle)
22. Total Number of Children (If none, write "None")
C.
Living
Deceased
Date of Birth (mm/dd/yyyy)
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
23. Complete the Following for Each Child
A.
Living
Name (Last/First/Middle)
D.
Deceased
Date of Birth (mm/dd/yyyy)
Living
Name (Last/First/Middle)
Deceased
Date of Birth (mm/dd/yyyy)
Form N-644 (08/01/12) Y Page 2
B. Information About the Decedent (Continued)
Certificate of Applicant
E.
Living
Deceased
Name (Last/First/Middle)
Date of Birth (mm/dd/yyyy)
I certify, under penalty of perjury under the laws of the United States
of America, that the information in Part I is true and correct.
Date
Signature
F.
Living
Deceased
Name (Last/First/Middle)
G.
Living
Date of Birth (mm/dd/yyyy)
Address (Street Number and Name, City/Town, State/Province,
Country, Zip-Postal Code
Deceased
Name (Last/First/Middle)
Name (Print or Type)
Date of Birth (mm/dd/yyyy)
Part II. To Be Completed by the Applicable Executive Department
1.
No Active Duty Records Found for This Individual
2.
No Casualty Records Found for This Individual
3.
Name of Decedent Correctly Shown
4.
Name of Decedent Different in Records
6. Individual Entered Service Under the Lodge Act?
Yes
No
Unable to Determine
Record of Death Found
(Complete a and b)
7.
a. Date of Death (mm/dd/yyyy)
(List name shown in records)
5.
b. Death resulted from injury or disease incurred in or
aggravated by active duty service during a period of
military hostilities specified by law?
Active Duty Service Records Found
(Complete a through f)
Yes
a. Branch of Service
No
Unable to Determine
8. Certification
I certify the information given here concerning the
b. Date Entered Active Duty
(Check one or both, as appropriate)
Service
c. Place Entered Active Duty Service (City/State/Country)
Death
of the individual named on this form is correct according to
the records of the (name below).
(Specify Executive Department)
d. Service Number
e. Date Released From Service (mm/dd/yyyy)
Signature
f. Honorable Service During a Period of Hostilities
(If no is checked, please provide an explanation)
Title
Yes
No
Date
Phone number
E-mail address
Form N-644 (08/01/12) Y Page 3
Part III.
To Be Completed by the Department of Defense, Washington Headquarters Services, Directorate for
Information Operations and Reports
B. Unable to Certify
A. Certification
Based on the information received from the Department
of Veterans Affairs concerning the death of the
individual named on this form, I am unable to certify
that the individual died as a result of injury or disease
incurred in or aggravated by service during a period of
hostilities specified by law.
Based on the information received from the Department
of Veterans Affairs concerning the death of the
individual named on this form, I certify that the
individual died on:
Date (mm/dd/yyyy)
as a result of injury or disease incurred in or aggravated
by service during a period of hostilities specified by
law.
Date
Signature
Signature
Date
Title
Title
NOTE: Space below (Part IV) for use by U.S. Citizenship and Immigration Services Only
Part IV. To be Completed by U.S. Citizenship and Immigration Services
Applicant Authorized Next-of-Kin or Representative
Action Block
Positive Certification Military Service
Positive Certification Service Connected Death
Place of Enlistment Qualifies Under INA Section 329 (a)(1)
Decedent Admitted for Lawful Permanent Residence
Cert. #
Date Mailed
A#
Reg. Mail #
Initial Receipt
Resubmitted
Relocated
Rec'd
Sent
Completed
App'd
Denied
Ret'd
Form N-644 (08/01/12) Y Page 4
File Type | application/pdf |
File Modified | 2012-08-01 |
File Created | 2007-08-28 |