Page 1,
Part 1. Information
About Service Member
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[Page 1]
START HERE - Type or print in
black ink.
Part 1. Information About
Service Member
…
4.
USCIS
Online Account Number (if any)
5.
Date
of Birth (mm/dd/yyyy)
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[Page 1]
START HERE - Type or print in
black ink.
Part 1. Information About
Service Member
…
4.
Social
Security Number (if any)
5.
USCIS
Online Account Number (if any)
6.
Date
of Birth (mm/dd/yyyy)
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Page 1,
Part 2. Service
Member’s Certification and Signature
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[Page 1]
Part
2. Service Member's Certification and Signature
Service
Member's Certification
I
authorize release of information contained in this request,
supporting documents, and from any of my records that USCIS may
need to determine my eligibility for the immigration benefit that
I seek, and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
…
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[Page 1]
Part
2. Service Member's Certification and Signature
Service
Member's Certification
I
authorize release of information contained in this request,
supporting documents, and from any of my records that the
U.S. Citizenship and Immigration Services (USCIS)
may need to determine my eligibility for the immigration benefit
that I seek, and to other entities and persons where necessary for
the administration and enforcement of U.S. immigration laws.
…
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Pages 1-2,
Part 3. Certifying
Official Attestation
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[Page 1]
Part
3. Certifying Official Attestation
…
[Page
2]
Information
About the Certifying Official
Branch
of Service
Unit
(such as Military Base, Vessel, Battalion, Brigade)
Work
Telephone Number
Military
Email Address
Certifying
Official’s Signature
Official
Signature
Date
of Signature (mm/dd/yyyy)
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[Page 1]
Part
3. Certifying Official Attestation
…
[Page
2]
Information
About the Certifying Official
4.
Branch
of Service
5.
Unit (such as Military Base, Vessel, Battalion, Brigade)
6.
Work
Telephone Number
7.
Military
Email Address
Certifying
Official’s Signature
8.
Official
Signature
Date
of Signature (mm/dd/yyyy)
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Page 2,
Part 4. Remarks
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[Page 2]
Part 4. Remarks
Provide any derogatory information
in your records relating to the service member’s character,
loyalty to the United States, criminal or unlawful conduct
investigations, pending court martials, convictions, discharges
characterized as other than honorable, bad conduct, or
dishonorable, or other matters concerning his or her fitness for
citizenship. If you need extra space to complete this section,
please provide a signed written statement.
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[Page 2]
Part 4. Remarks
1.
Provide any derogatory information in your records relating
to the service member’s character, loyalty to the United
States, criminal or unlawful conduct investigations, pending court
martials, convictions, discharges characterized as other than
honorable, bad conduct, or dishonorable, or other matters
concerning his or her fitness for citizenship. If you need extra
space to complete this section, please provide a signed written
statement.
|