4 Foreign National Residence History

OMB No. 0607-XXXX

Foreign National Residence History

Please list where you have lived for the five (5) most recent years (most recent first)

Full Name of Applicant: (First, Middle, Last)

Date From (MM/DD/YY)	Date To (MM/DD/YY)	Address (Street, City, State/Province, Country, Postal Code)

We are conducting the Data Security Requirements for Accessing Confidential Data collection under the authority of Title 13, U.S. Code, Section 23c. Providing the requested information is required to obtain Special Sworn Status (SSS). Personally identifiable information collected includes name, telephone number, age/date of birth, race, sex, travel records, work email and citizenship, etc.]. Title 13 of the U.S. Code protects the confidentiality of all your information. Violating the confidentiality of a respondent is a federal crime with serious penalties, including a federal prison sentence of up to five years, a fine of up to $250,000, or both. Only authorized individuals have access to the stored data, and the information you provide to the Census Bureau may only be used by a restricted number of authorized individuals who are sworn for life to protect the confidentiality of your individual responses. For more information about how we protect your information, please visit our Web site at census.gov and click on "Data Protection and Privacy Policy" at the bottom of the home page. This page also includes information about the collection, storage, and source, etc., of these records. Click on "System of Records Notices (SORN)" and look for Privacy Act System of Records Notice COMMERCE/DEPT-13, Investigative and Security Records.

This is a voluntary collection, however, failure to provide the information may delay or prevent the individual from receiving approval to access data. This collection has been approved by the Office of Management and Budget (OMB) The eight-digit OMB approval number that appears at the upper right of the form confirms this approval. If this number were not displayed, we could not collect this information. We estimate that completing this form will take 15 minutes on average. You may email comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to [email protected]. Use “Paperwork Reduction Project 0607-XXXX” as the subject.