Name of Child: (Last. First, Middle)
Child's Alien Registration Number:
A#:
Estimated Total of Assets: $
Estimated Average Weekly Earnings: $
Citizen of What Country:
Now Residing At: (City and Country)
Birth Date: (Month. DaJc Year) Birth Place: (City and country)
Immigration Status
of Child
A#:
Estimated Total of Assets: $
Estimated Average Weekly Earnings: $
Name: (Last, First, Middle)
Alien Registration Number:
A#:
A#:
Estimated Total of Assets: $
Estimated Average Weekly Earnings: $
Citizen of What Country:
Relationship to Me:
Immigration Statu
Birth Date: (Month. Day, Year) Birth Place: (Place and Country)
of Listed Relative
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I 44) If your application is denied, would your spouse and all of your children accompany you to your:
A#:
Country of Birth -
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U y e s 0 NO
If you answered "No" to any of the
responses, please explain:
Country of Nationality - 0
Yes 0
No
Country of Last Residence - 0 Yes 0
No
45) Members of my family, including my spouse andlor child(ren) 0 - have
- have not received public or private relief or
assistance (e.g., Welfare, Unemployment Benefits, Medicaid, AFDC, etc.). If any member of your immediate family has received
such relief or assistance, please give full details including identity of person(s) receiving relief or assistance, place, dates for which
relief or assistance was received, and total amount received during this time:
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Complete Address of Current Residence:
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