Form I-777 Application for Issuance or Replacement of Northern Mari

OMB No. 1615-0042; Expires 11/30/2011

Form I-777, Application for Replacement
of Northern Mariana Card

Department of Homeland Security
U.S. Citizenship and Immigration Services

Part 1.

Information About You (Person applying for a Northern Mariana Card)

Family Name (Last Name)

Given Name (First Name)

Middle Name

FOR USCIS USE ONLY
Returned
Receipt
Date

Home Address - Street Number and Name

Apt. #

Date
Resubmitted
Date

State or Province

City

Date
Zip/Postal Code

Reloc Sent

Country

Date
Mailing Address - Street Number and Name

Apt./Suite #

Date
Reloc Rec'd

C/O (In care of):

Date
Date
State or Province

City

Applicant

Interviewed
on
Zip/Postal Code

Country
A-Number

Daytime Phone # (Area/Country Code)

Gender
Male

Remarks
Female

Date of Birth (mm/dd/yyyy)

Place of Birth (City/Town and Country)

A-Number (If any)

U.S. Social Security # (If any)

Father's First Name

Mother's First Name

Part 2.

Action

Requested Action

Check the classification that best describes your eligibility. (Check one box)
A.

My Northern Mariana Card was lost or destroyed.

B.

My Northern Mariana Card was stolen. (You must attach a copy of the police
report.)

C.

My Northern Mariana Card was damaged. (You must attach the damaged
card.)

To Be Completed by
Attorney or Representative, if any.
Fill in box if G-28 is attached
to represent the applicant.
ATTY State License #
Form I-777 (Rev. 11/19/10) Y

Part 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)

Present

To (mm/dd/yyyy)
Present

2. At what address(es) have you lived for the last ten years? (List present address first)
Street Address (Number and Name)

From
(mm/dd/yyyy)

City, State

To
(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.
Daytime Phone Number (with area code)

Signature

Date (mm/dd/yyyy)

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