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Appendix SELECTED FORMS The forms that appear below include only those that are referred to in this report; they are used to collect a major portion of the available information about migration to the United States. Because of the very large number of forms used in connection with immigration, it was not possible to include a comprehensive array. The INS forms are listed in alphabetical and numeric order, followed by those used by other agencie 159

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160 Sponsoring Fonn Agency Numbe r . . INS State Dept. Customs Customs NCHS ACVA SSA ORR G-23 G-325 C G-540 G-541 G-542 I-53 I-92 I-94 I-213 I-485 I-551 I-589 I-590 I-591 I-643 N-400 N-600 OF-155 A 5905 6059 B HRA-161 ACVAFS Form #1 SS-5 ORR-6 Form . Report of Field Operations: Selected pages Biographic Information--Applicant for Refugee Status Daily Record of Primary Inspections- CINSP-8 Semiannual Report of Primary Inspection Activity--CINSP-8 Semiannual Report of Hourly Workloads- CINSP-8 Alien Address Report Aircraft/Vessel Report (Passenger manifest) Nonimmigrant Arrival/Departure Form Report of Deportable Alien Application for Status as Permanent Resident Alien Registration Receipt Card Request for Asylum in the United States Registration for Classification as Refugee Assurance by a United States Sponsor in Behalf of an Applicant for Refugee Status Statistical Data for Refugees. Collected by the INS for the Department of Health and Human Services Application to File Petition for Naturalization Application for Certificate of Citizenship Immigrant Visa and Alien Registration Customs workload form Customs Declaration Card Standard Birth Certificate--1978 revision Refugee data form--American Council of Volunteer Agencies Application for a Social Security Number Card ORR Quarterly Performance Reports, Schedules B and C. Page . 161 169 170 171 172 173 174 175 176 177 180 181 185 187 188 189 192 195 196 197 198 199 200 201

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169 U.S. Department of Justice ~ FORM G-325C - ()!\~113 No. 111.~-()()~6 Immigration and Naturalization Service BIOGRAPHIC INFORMATION \~)~)roval expires t-:~()-X, tF ^ - ILV - ~ - C) DRIEST a) ( - IDD~C Nits) 0 - ~1 ~el~7HD^TE ( "O. - Do ~ - V,'.} N^TION^LITY O ~c _ ALL OTtlER N^MES USED FATFtER MOTl4ER {~ - e.. "A - C) CITY AND COUNTRY OF ElIRTH . . - F^MILY N^ME FIRST N^ME DATE, CITY AND COUNTRY OF BlRrH t' Kr4OWrd) CITY AND COUNTRY OF RESIDENCE 14USeAND on WIFE FAMILY NAME FIRST NAME 81RTl4DATE CITY & COUNTRY OF BIRTH DATE OF MARRIAGE PLACE OF MARRIAGE ( - Am. so ANTS) Arm genre. CIVIC "block P4^M~) 1 1 1 1 1 . . FOItMER HUSB^NDS on WIVES (elm ~ Ho COCKS BELOW. In "O~C, ST^~ '' - Offs''.} F^MILY NAME (boa ware, News - SINCE MAMA) ' 1 ' I FIRST N^ME | elRTHD^TE | D^TE At PL^CE OF MARRIAGE| DATE AND PLAN' OF TERMINATION OF MARRIAGE A~rLIC^NT'S RESIDENCE LAST FIVE YEARS. LIST PRESENT ADDRESS FIRST. FROM _ STREET AND NUME,ER CITY PROVINCE OR STATE COUNTRY MONTH YEAR . l ArPLICANT S EMPLOYMENT LAST rlVE YEARS. | - rdomc, so Amp) LIST PRESENT EMPLOYMENT FIRST. FROM . ~_ OCCUP^TION MONTH YE^R . t I I i I I . _ . . . . . IF YOUR NATIVE ALPHABET IS IN OT14ER THAN ROMAN LET' rERs, WRITE YOUR NA ME IN YOUR ~ I^TIVE Ai PHABET REL OW: . ~ MONTH Y E A R . PRESENT TIME FULL NAME AND ADDRESS OF EMPLOYER 1 TO MONTH Y E ~ R PRESENT TIME APPLICANT FOR REFUGEE STATUS | PENALTIES- SEVERE PENALTIES ARE PROVIDED BY LAW FOR KNOWINGLY AND WILLFUt LY FALSIFYING I OR CONCE^LINC A MATERIAL FACT D^'C (TIC - MARC OF ~PrLIC^~) ~ APPLICANT: BE SURE TO PUT YOUR NAME IN THE BOX OUTLINED BY HEAVY BORDER BELOW. | COMMUTE TI415 Box (FAMILY HA - at) (GIVEN NAME:) (MIDDLE NAMIC) FORM G-325C (Rev. 10-1-82)Y

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192 U.S. DEPARTMENT OF JUSTICE I~Y16"SIO?' AND NATURALIZATION SERVICE ORB No. 1115 0018 Approval Expires 7/31/85 Tako or mall this application to: IlIMIGIlATION AND NATURALIZATION SERVICE ( ~ ) . ~ APPLICATION FOR CERTIFICATE OF CITIZElSNIP l Fa: Scour 1 1 Date (FulL True Name, without Al>breviatione) . . . .. ... ......... ....... . .. (Apartment nil - her, Street addre - , end, if swropriate, ..in care ot-') ..... .. .... ......... . . . . .. . . ....... ......... (City) (County) (State) nee . . (ZIP Code) ALIEN REGISTRATION | (Telephone Number) (SEE INSTRUCTIONS. BE SURE YOU UNDERSTAND EACH QUESTION BEFORE YOU ANSWER IT.) I hereby apply ~ the Commissioner of Immigration and Naturalization for a ce~iffca~ showing that I am a citizen of He United States of America. (1) I ~ bont in .............. .... . . . . on (Cite) (I) ply personal d;eacription is: Sex ...... ; complexion . . . . . (8~" or o~untrr) , . .. ...... ( Yontl' ~( Dear ) ( Y - r ~ ........ .... ; color of eyes ; color OI nalr Nelsen' . bees Inches; Vegan pounds; risible distinctive marks .. . ........... Ilarital Stun: O Single; O Varied; O Divorced; O Widow(er). (3) I arrived in the United States at .... .. ... ...... ... . on under the name ... .... .. . (City and State) he moo n ~ ^, (Mono\ (Dar) (Year} (Name Or ably or over means of arrival) O on U.S. Passport No issued to me at . ...... on ... .............. .. O on an Immigrant Visa. O Other (specify) . .. ~ ---- (Der) (Year) (I) FILL IN THIS BLOCK ONLY IF YOU ARRIVED IN THE UNITED STATES BEFORE JULY 1, 1924. (a) lay lot permanent foreign ~idenee are ... (c - ) (a) I tools the ship or other conveyance to the United States at .......... ~ Country ~ ...... . . .. ............... . .. . .. ~ Colmtrr) (CItr) (c) I w~ coming to .. .... . . ... . at ... . . .. (Now of person in the United Stow (City and State where Ill person w~ lions) (d) I traded to the United States With . ............................................ .... ............... - -------- (N~_ of I_-n or rustic with whom ~ Clod, Id t-ir rchtiooship to you. it any) [S) Ileve you been out of the United States since you Brat arrived ~ O Yes O No. If 4'Yes" kill in the following infonnstion for mere Seance. =~: DA" D - ~ (6) I _ _ _ _ filed a petition for naturalization. (have) ( have not) PORT OF RETC'RN TO SHE UN'!rED STATES ~ ~Dam Recount NAME OF AIRLINE, OR OTHtR ~IEA}SS USED TO RETURN TO . . . . . . . . . ... ....... . .......... . ..... .... ........ ............. ... . ........... . .......... . . . . ... .... ....... .. ... ... ............ . .. , ................. ............ . .... .. ... . . . . . . . .... .............................. .. ................ ................... .. .. ....... . . ........ .. . . . .. . . . . . . . . .. ......................... , . .. ................. ...... .. . . . .. ...... . . . . . . .. . . ....... ........ .. . .. ..... ..... ..... ..... ..... ..... .... .......... (If "have", attach full explanation.) TO T.E AmlCA - .- De cat write ~a the Mob 11~ IBM. Continue ~ mat - Be. ARRIVAL R1 :CORDS EXAMINED Card Index . .... ........... - -- I"ex boom asp. ARRIVAL RECORD FOUND All.., ales . ... ... ......... .. .. ..... .... .. Form N~600 (Rev. 5~5~83)N planner . .. . llantal Stun........... .. .. ... . . Age.. (Signature of "reDn males Greta (1)

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193 ICONTItIUE HERE) (7) I cell- United States eiti#nship through-~ (check whichever applicable) O Other; O mother; 3 both parenb; O "opff~ep.~t(~) O husband (8) 11, f~er's - - e ~ . ... ........... . ; he was born on (City) (state or country) am1 ~ of ~th.) .. . .. .. . ... _ .. .... .. . . . . _ (Honth) (Day) (Year) (Street uldr~. city, and State or country. It de d, ferrite. U. helms ~ d~itie.~ ^~. TIn;~ - -I by O birth; ~ naturalization on . (llonth) (Day) (Year) ............ . . Certificate of Naturalization No (Near of court, city. and State) O through his parent(~), and . ~ ) ~ ~ .. issued Certificate of Citizenship No. A or AA ... .. (If known) His former Alien Registration No. was ... He ~ )lost United States citizenship. (If citizenship lost, attach full explanation.) He resided in the United States from to , from to ; from to (Y-r) (Year) (Year) (Year) (Year) (Year) from . . . to ., from . to , I am the child of his marriage. (Yam) (Y - r) (Year) (Year) (~et, Id, ad, etc.) (9) lily mother's present name is . . .; her maiden name was she was born on . . . .. , at (Month) (Day) (Year) (Street addreca, city, and State or country. If dead, write "dead" and date of death.) by O birth; O naturalization under the name of . . on . ... ... in the . ( Month) (D - ) (Year) ; she resides .... ... . .. . .. .... .. ... .... . . . . ...... (City) (State or country) She became a citizen of the United States (Name of court, city, and State j Certificate of Naturalization No . ; O through herparent(~),and issued Certificate ~ wee) ( was not of Citizenship No. A or AA . . ( If known ) Her former Alien Registration No. was She lost United States citizenship. (If citizenship lost, attach full explanation.) (me) (tan not) She resided in the United States from to , from (Year) (Year) to _______, from ______ _ to __ ; I am the child of her (Year) (Year) (Year} (10) Sty mother and my father were married to each other on at (Month) (Dar) (Year) (City) (State or country) (11) If clam is through adoptive parent(s): I was adopted on (Month) (Day) (Year) at . . _ _ ( City or town 3 ( State ) ( Country ) who were not United States citizens at that time. (12) My . served in the Armed Forces of the United States from ~ Others (mother) to ; from to ; from (Year) (Year) marriage. _ (lat. Id, Id, etc.) by my to and .. . ... . honorably discharged. (Date) ~ was) ( was not) (13) I _ lost my United States citizenship. (If citizenship lost, attach full explanation.) ( have) (1 - ve not) (14) I submit the following documents with this application: Nature of Document (2) (Year) (Year) (Year) .. ... . . .. (Name of Court) . (mother, father, Darente) . . (Date) Names of Persons Concerned

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194 - (16) Fill in this block if your brother, sister, mother or father e~rer applied to the Immigration Service for a certi~cak of citizenship. . . _ Name OF IteLAS'" Rc~r~oNalilp I Mate of Birth . . WHEN APPLICATION| C - Fact NO. A~ F1 - NO.. 1, 1CWOwH. SUDMIrT~D , AND LocA7102. or Oral" -- _ . (16) Fill in this block only if you are now or ever have been a married woman. I hare been married . ..... time(s), a. follows: (I. 2, S. etc.} DATE MARRIED | MARC or H UB8AND In Mince H" B"N nea~r.~"D C's~ztNaH', or HUSBAND Date Marriase How Marriage Ended Ended ( Dacth or dlivorce ) _ _ (17)Fill in this block only if you claim citizenship through a husband. (Marriage must have occurred pmor to September t, at 1 9~.) Name of citizen husband . .......... . ...... . , he was born on . ... ...... ............. (Give full and complete name) (Month) (Da,) (Year) .; and resides at .. ,_ _ _,,,,,,,,,,,,,, ,.,_ _ _. _._ ~ - ~" ID "L ._ _ - --.- - -.--------------------------------~----- - ~ --a----' (City) (Sate or country) (Street addle, city, and St te or country. If deed, write . _ ... He became a citizen of the United States by O birth; O naturalization on . .. "dead" and date of death.) (month) (De,) (Yeer) in the . ... . .... . . Certificate of Naturalization No. . (N. - ne of court, city, and State) G through his parent(~), and .......... issued Certificate of Citizenship No. ~ or AA ( treat ( wry not) He .. ..... since lost United States citizenship. (If citizenship lost,attack fun cxphnation.) ( h - ) (has not) I am of the . . . . . - - - . . race. Before my marriage to him, he was married ... . . .. time(~), as follows: it. 2. I. etc., I, l(~ - HA. B - N TeRuIr.AseD: Date Marriage Ended How Ferrite Ended (Dam or di~orec) (18) Fill in this block only if you claim citizenship through your stepfather. (Applicable only if mother married U.S. Citizen pmor to September *2, 1920.) The full name of my stepfather is at ........ ... ...... . . ; and resides at . .. .... . (City) (State or country) . ; he was born on ( Honth ~ ~ De, ) ( Year ~ (Street address city; ni Si - the or country li dead; write ...... . He became a citizen of the United States by O birth O naturalization on "deed" and date of dentin ) ' in the . (Month) ( Day) (Year} .... .... . ... Certificate of Naturalization No .............. (N - ne of court city and State) O through his parent(s), and issued Certificate of Citizenship No. ~ or AA (amp) (wee not) He .... . since lost United States citizenship. (If atisc~uAiplost,etteeh fuU cxploatu~n.) ( h - ) ~ h" not ~ He and my mother were married to each other on . .. . at . . (Month) (Day) (Year\ {City and Ste e or country} My mother is of the . . . race. She issued Certificate of Citizenship No. ~ .... ... Amp) (arm not) Before marrying my mother, my stepfather was married . .. . time(~), as follows: (t, 2 ~ ete ) . _ D^se h(AanIED Near or W.'" -_ It HAa - A" H." B"N TERMINATED: Date liarriace Ended How lI-rri~e Ended ( D - tl' or titeorec ) _ (19) I _ __ _ _____ previously applied for a certificate of citizenship on , at _ _ - (beve) (babe not) (20)- of Deraon predefine torm it other than apDIieent I deehre that thin document was prepared by me at the request of the applieent and h t - - on 11 in formation of which I he ve an, knowledge . _ SI6NATU - : I Dam: (3) (Date) ( OlBee) ( 8tC N ~ ) (8~ of pplie~t or p~t or Words)

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195 Appendix D Part IV _~ Fo rm OF- 1 55A Q.PIlO~~t fORM ~ 55A ~O 821 (tornterly OF 15$ DtPT Of STATE 'JS~ /54r) ~1 '26 770: IMMIGRANT VISA AND ALIEN REGISTRATION l ('Jr\! Y~InC) (.~!iddl~ .\a,>~) ~ THE IMMIC RANT NAMED ABOVE ARRIVED IN THE UNITED Y STATES VIA (.~, t~f y`~,i `'r J1i'~f't l'`~. `~/ ~rrr/`a/} ~ Of: (~mi/y Name) ACTION SY IMMIGRATION INSPECTOR =~EET ADDRESS. I~CLUDE. IN C4RE OF & APT# ~F AP IN Ti1E UNITED STATES I _ 1 SEC 21 2(0H 14) 1 IABOR CERTIFICATION O NOT APPLICABlE O NOT REQUIRED O~D IV- r ~ CITY AND COUNTRY Of BIRTH ~ ~ __ ~ _W CITY AND COUNTRY OF lAST RESIDEN\E 1 \ -_~ , . . _ _ MARIrAl STATUS MOTHER S F1 --NAM FAT S flRST NAME []M lis LI~ [)~Lls~P ~( . CITr STAr~ZIP CODE IF AVAICABlE so I ss . , :i MO DAY YR OF BIRTH O rHE t"MIGRANr HAb BEEN PREVIOUSIY Ir~ THE UNITED STATES ,r __ _ . . _ _ _ _ . {~S FILE ~ IF KNOWN _ . + _ INE/;i8lIITY F()g VISA w^~ED UN0,F. 5EctlOt. \5Z~ 21 21e) 0 21 21h 0 212lg) 0 2'i' _. _ _ _ _ _ _ _ _ NAllONAI ITY - ~CUPATION This visa is issuod under Scctir';'lity A~ t, ;~nLI up<,n the hasi~ `,f thc f;~ct~ staled in the application. P`~sscssi`,n c~f a ~isa does '~'title thc hcarcr t<, cr~:e~r the Unitc~l St;~tc~ ~f al th~ ti','~ hc seeks to enter he is found t`, hc inadmissible. IJ~,n~rival ''~ the Ur~ited States. ~t must l'` ~urrcr~dere`! tt~ .' United Statcs Immigrati`,n ()fE'ccr \ AME RICAN ~_ . . ~ / Consulor Otficor of 1he United Stotes o\~eriCa =t Torift No 21 Fee Poid S7S locol Cy, Equiv. ACTION Of I.J. VISA TU ~ O ~ 2 . ~cr,o~ o~ APPE^l ~ IMMIGRANT CLASSIFICATION CtASSIFICATION SYMBOt fOREIGN STATE OTHER AREA lI"lTATION IMMIGRANT VISA NO ISSUED ON (soy) ("onthI IYeo THE VAllDITY Of THIS VISA EXPIRES MIDNIGHT AT THE ENr) OF [soy) I"on~h) !Yearl PASSPOR! .. _ NO. ._ OR OTHER TRAVEL DOCUMENTS (Describe, ISSUED ro BY ON EXPIRES IV- ~I FOREIGN ~ FFAIRS ~NUAL JU N t 4 1q Q~

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196 . 131 m . ~ . _ J ~ l 1 1 1 . 1 ~ .. _~ LIT T hi - "i. ''a 1' eia Ial ~ 1 . 1 ~ 1 _ `3 1 Cat 1 -1 1 . rim I I r I I 1 1 1 -- - ~ ~ ~ ~ ~ I ~ I T ~ ~ _ ~ Jo 1 - ._ :- 1 1 1 1 _ ~ 1 1 1 1 111 1 1 1 to 1 -.1 i, ~] S ~N U r F~- 11 ; ; O U C V.

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197 .,~. WELCOME TO THE i.' U N ITED STATES DEPARTMENT OF THE TREASURY UNITED STATES CUSTOMS SERVICE CUSTOMS DECLARATION ins n 0~. Al -. . Each arriving traveler or head ot family must provide the following intormat,on (only ONE written declaration per family is required): 1. Name: ~ Lest . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ fits, _ _ _ _ _ _ _ _ _ _ M,aal. It'll,./ 2. Number of family members traveling with you -------------------- 3. Date of Birth: --A-~-,b /~ Cry -it- r-' ~~ 4. AirlinelFlight: ------------- 5. U.S. Address: ----------------------------------------------- 6. lam a U.S. Citizen If No, Country: --__________________________ 7. I reside permanently in the U.S. tf No, Expected Length of Stay: -------------- 8. The purpose of my trip is or was O BUSINESS a PLEASURE 9. 1 am/we are bringing fruits, plants, meats, food, soil, birds, snails, other live animals, farm products, or l/we have been on a farm or ranch outside the U.S. 10. 1 amlwe are carrying currency or monetary instruments over $10,000 U.S. or foreign equivalent. 1. The total value of all goods llwe purchased or acquired abroad and am/are bringing to the U.S. is (see instructions under Merchandise on reverse side; visitors should report value of gifts only): YES NO O O YES NO O O YES lo YES lo _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ., c twos NO lo NO lo ~- SIGN ON REVERSE SIDE AFTER YOU READ WARNING. (Do not write brow to is line.) INSPECTOR'S NAME BADGE NO. STAMP AREA Paps Deduction Act Notice: The P4~ P auction Act d 1980 ~ we muet 1~1 you Baby we ar cotbct~ng tt~le infomeation. how _ w111 Has it and ~thcr Mu ~vc to gee It to us. Verb ask for the information to cany out the Custome. Agacultu~. and Cut 1~ d the Unild Stat-. Verb need It to ~ that try_ are complying with them lam and to albeit us to tigue and coUcct the rot amount d Outlec arm taxca. Your depone. is mandatory Customs Form 6059B (102584) WARNING AGRICULTURAL PRODUCTS To prevent the entry of dangerous agricultural pests the following are restricted: Fruits. vegetables plants plant products soil meats. meat products birds snails. and other live animals or animal products. Failure to declare all such items to a Customs/Agriculture Officer can result in fines or other penalties. CURRENCY AND MONETARY INSTRUMENTS The transportation of currency or monetary Instruments regardless of the amount. Is legal however if you take out of or bring into (or attempt to take out of or bring Into) the United States more than $10 000 (U.S or foreign equivalent. or a combination of the two) In coin. currency. travelers checks or bearer Instruments such as money orders checks. stocks or bonds you are required by law to file a report on a Form 4790 with the U S Customs Service If you have someone else carry the currency or Instruments for you you must also file the report FAILURE TO FILE THE REOLIIRED REPORT OR FALSE STATEMENTS ON THE REPORT MAY LEAD TO SEIZURE OF THE CURRENCY OR INSTRUMENTS AND TO CIVIL PENALTIES AND/OR CRIMINAL PROSECUTION MERCHANDISE In Item 11 U.S. residents must declare the total value of ALL articles acquired abroad (whether new or used. whether dutiable or not and whether obtained by purchase. as a gift. or otherwise) which are In their or their family s possession at the time of arrival. Visitors must declare in Item 11 only the total value of all gifts they are bringing with them. The amount of duty to be paid will be determined by a Customs officer U.S. residents are normally entitled to a duty free exemption of $400; non~res~dents are normally entitled to an exemption of $100. Both residents and non-res~dents will normally be required to pay a flat 10/0 rate of duty on the first $1000 above their exemptions It the value of goods declared In Item 11 EXCEEDS $~.400 PER PERSON. then list the articles below and show price paid or. for gifts. taker retail value DESCRIPTION OF ARTICLES I PRICE | CUSTOMS USE TOTAL PRICE _ _ _ _ .~ IF YOU HAVE ANY QUESTED_ A_ w~r - ~ REPORTED OR DECLARED ASK A CUSTOMS OFFICER. I have read the above statements and have made a truthful declaration. S/G`VA [URE DA rE {MO"~/O.YIY - ,, Customs FORn 6059B (102584) (BaCk) GPO: 1984 0 - 458-903

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198 l 12~1~1 ~- e z ~ z =",,,o ~ ~ J. ~ it ~ ~ ~ ~ ~ <~ N0151~3H 8L6t SOIlSll~lS 141~3~ ~0d H31N30 ~NOI1~N-301~35 H1~3~ ol~8nd-3~3M ant N011~0~03 U11~3~ do lN3Wl~VdBa ?

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199 AMERICAN COUNCIL OF tIOLUNTAR~Y AGENCIES FOR FOREI(;N S ERVICE, 1 ~.c 200 Park Avenue South - New York, N.Y. 10003 Date: File ID ~Present Location: The fit flowing persons: 1. 2. 3. 4. 5. 6. r ~ 8. 9. 10. 11. 12. Name . A Number Date of Birth Sex Place of Birt h ~ . ~ have been accepted for resettlement under the auspices of: Voluntary Agency (Principal Sponsor) Tel : Airport of Final Destination: Special Instructions: Loc al Sponsors Tel: This agency agrees to assign the principal refugee named above to obtain `:~;lpl `~ ~ ~ ~I)' and housing for him/hersel f and family, i f any . Signa tu re Authorized volag Representation ACVAFS Form $1

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200 DEPARTMENT OF HEALTH AND HUMAN SERVICES SOCIAl SECURITY ADMINISTRATION form Approved OMB No. O9000S6 FORD SS-5 - APPLICATION FOR A SOCIAL SECURITY NUIIIBER CARD (Original, Replacement or Correctlon) MICROFILM REF. NO. (SSA USE ONLY) . . . Un-~ the required In1Ormatlon le pro~lded, we nay not be able to laud ~ Soclal Security Number (20 CFR 422-103(b)) . _ , INSTRUCTIONS ~ Before completing this form, please read the instructions on the opposite page. You can type or print, using TO APPLICANT ~ pen with dark blue or black ink. Do not use pencil. ~1 ~1 1 0 - m 2 esP 3 ~8 6 9 FN, PNO 101 L NLC 0h 11 ASO _ _ NAME TO first : Middle ; ' ~~' BE SHOWN ' ~ ON CARD I _. . 1 FULL NAME AT First ElIRTId (IF OTHER THAN ABOVE) OTHER NAME(S) USED MAILING ADDRESS CITY CITIZENSHIP (Check one only) O a. U.S. citizen O b. Legal alien allowed to work c. Legal alien not allowed to work O d. Other (See instructions on Page 2) SEX 4 ~SEX O MALE FEMALE . . ' Middle ' I 1 1 _ sstreet/Apt. No., P.O. Box, Rural Route No.) STE ETB DATE MONTH ~ DAY , YEAR | AGE | PREA5GEE| 8 | OF ~C MOTHER'S First' Odd e NAME AT I HER BIRTH ~ ' FirstI Mld(lle I Last FATHER'S NAME ~ a. Has asocial Security number card ever I_ | =1 ~MONTH , YEAR beenrequested for the person listedin item IJ YES(2) LJ NO(~) LJ Don't know(~) It y s, ~j _ . _ ~ b. Was a card received for the person listed in ~ YES(3) t1 NO(1 ) ~ Don't know(, ) If you cocked yes to or b, comports item 1 ? Items c through e; otherwise 90 to Item 11. STATE ZIP RACE/ETHNIC DESCRIPTION (Check one only) (Voluntary) O a. O b :;1 c d. Northern American Indian or Alaskan Native 21 e. White (not Hispanic) ZIP CODE it. Asian, Asian-American or Pacific Islander (Includes persons of Chinese. Filipino, Japanese. Korean, Samoan. etc.. ancestry or descent) Hispanic (Includes persons of Chicano, Cuban, Mexican or Mexican- American. Pueno Rican, South or Central American, or other Spanish ancestry or descent) ,. Negro or Black (riot Hispanic) STATE OR FOREIGN COUNTRY ~ FC, ~ O Last (Her maiden name) c. Enter the Social Security number assigned to the ~ ~I l person listed in item 1. L_ LJ L J LJ LJ I LO LJ LJ , d. Enter the name shown on the most recent Social Security c' Err e. Date of ~ MONTH , DAY , YEAR issued for the person listed in item 1. P birth correction _ Do (See Instruction 10 on page 2) ~ ~MONTh1 ~DAY ~YEAR I Telep hone ~ umber where we ~HOME ~OTHER TODAYS ~1 ~ Ican reach you during the _ DATE ~, 1 ~ | day. Please include the area code. ~ WARNING: Dell~tely tuml~lng (or causing to be hmbhed) blue Intom'stlon on this apDlicatlon is ~ crime punlehable by tine or Imprisonment, or beflh. . IMPORTANT REJOICER: SEE PAGE 1 FOR REQUIRED ~IDENTIARY DOCUMENTS. YOUR SIGNATURE WITNESS (Needed only it signed by mark "X") t)O NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY) r . . . I ASSIGNED Cl [A ~ ~ ~ O O O O O pQC INTC |CAN TYPE(S) OF EVIDENCE SUBMITTED Form SS-S (5-84) Destroy prior editions YOUR RELATIONSHIP TO PERSON IN ITEM 1 O Self ~ Other (Specify) WITNESS (Needed only if signed by mark "X") ale lo, - MANDATORY ~ IN PERSON Am I NTERV I EW CONDUCTED _ IDN IT\/ 3 DTC |SSA RECEIPT DATE l NPN l SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING EVIDENCE AND/OR CONDUCTING INTERVIEW DATE DATE DCL

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