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Citizen of What Country: Now Residing At: (City and Country) Name of Child: (Last. First, Middle) (mm/dd/yyyy) Child's Alien Registration Number: Birth Date: (Month. DaJc Year) Birth Place: (City and country) A#: Estimated Total o f Assets: $ A#: Estimated Total of Assets: $ A#: Estimated Total of Assets: $
Immigration Status of Child
Estimated Average Weekly Earnings: $
Estimated Average Weekly Earnings: $
Estimated Average Weekly Earnings: $
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44) If your application is denied, would your spouse and all of your children accompany you to your:
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Country of Birth Country of Nationality -
Uyes
0 NO
If you answered "No" to any of the responses, please explain:
0Yes 0No Country of Last Residence - 0 Yes 0 No
0-
45) Members of my family, including my spouse andlor child(ren) 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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Name: (Last, First, Middle) Alien Registration Number:
Citizen of What Country: Relationship to Me: Birth Date: (Month. D a y , Year) Birth Place: (Place and Country) (mm/dd/yyyy)
Immigration Statu of Listed Relative
A#:
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Complete Address of Current Residence:
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A#:
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(Internet Version)
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