Strunk Response 1
Strunk Response 1
Strunk Response 1
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' (PLEASE PRINT OR TYPE - PENCIL NOT ACCtPJABtEj<br />
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- . 1 I For Deparhent Decision 1<br />
I I<br />
I DEPARTMENT DF STATE<br />
I LarT,oN Jakarta. Indonesia<br />
POST ACTION<br />
a<br />
June 2 7 6 Ex,,,,,<br />
TO BE CONIPLW BY AN APPLICANT WHO BECAME A CITIZEN THROUGH NATURALIZATION<br />
1IMMtERATEDTOTHEU.S.IREStDEDCO~TIFIUDL?SLYINTHEU.S.<br />
(Month, y*ar)<br />
From (Year) T 0 [Yaar)<br />
PLACE NATURAL ZED (Ciry, starel<br />
1 I<br />
COMPLETE OHLY IF OTHERS ARE TO BE INCLUDED IH PASSPORT OR REGlUMTION AN0 SPMK GROUP PHOTOGRAPH<br />
1 I<br />
IWI FE'SJ (HUSBAND'SJ FULL LEGAL N~ME<br />
PLACE NATURA LlZEiJ (City, ~tute)<br />
I<br />
IWl~d51 (HUSBAN~'~) PLACE OF BIRTH Iclty, Stat* ur Provlnc-, Enuntryl<br />
NAME IN FULL OF CHlLDRFH IMCLUDEO<br />
NATURALlZATlOWCEFITIFICATENO.<br />
U Submrlted hersrirh<br />
ken and tdwned<br />
0 Previau.ly aubmittd<br />
NATURAL1 ZATIDN COURT<br />
=<br />
NATIVE BORN<br />
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NATURALIZED<br />
NATURALIZdTlON 'L<br />
useen and mrurnnp<br />
t<br />
NAfURALITATlON COURT<br />
I DATE NATURALfLED<br />
DATE US BIRTH (Ma..<br />
- . . - - I -- .. ---,<br />
PLACE OF BIRTH (City, st~Tprouinco, cauntw)<br />
I<br />
-- - .- - - -. - - -<br />
DATE OF BIRTH<br />
EVIDENCE OF PRIOR DOCUMEHTAnON DF ABOVE-HAMEI) PERSORS TO BE IIYCLUDED (For completion by Colrsular Dfficel<br />
CANCELEO O?<br />
3ATE OF REGISTRA-<br />
NAMES PASSPORT NO.<br />
DATE OF IS SUE OTHER<br />
DISP3SlTlUN<br />
TION OR<br />
BLRTH REPORT<br />
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DATE NATURALIZED<br />
Boy, Ymr)<br />
RESIDED IN U.S. (From-To)<br />
LOCATION DF<br />
OFFICE<br />
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OTHER EviD EMCE OF V.5. OTIZCN5HiP PRESENT m TState dirposttlwr)
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