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Form 2213
FACTS FOR DECLARATION OF INTENTION
U.S. DEPARTMENT OF LABOR
NATURALIZATION SERVICE
5062
NOTE.-A copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the
public-school teacher to each applicant for a declaration of intention, so that he can at his leisure fill in the answers to
the questions. After being filled out the applicant should take the form to the office of the clerk of court to be used
by him in properly filling out the declaration. Care should be used to state as near as can be remembered the day,
month, and year of arrival, as well as the name of the vessel on which the alien emigrated to this country.
TO THE APPLICANT.The fee of one dollar required by law for the declaration, must be paid to the clerk of the
court beforo ho commences to fill out the declaration of intention. No fee is chargeable for this blank, and none
should be paid for assistance in filling it out, as the Naturalization Examiner or the public-school teacher will help you
freo of charge.
My name is
Alexander Brown
Age: 55
years.
(Alien should state here his true, original, and correct name in full.)
(Give age at last birthday.
Also known as
(If alien has used any other name in this country, that name should be shown on lino immediately above.)
Occupation:
granite Cutter
Color:
White
Complexion:
Sandy Fair
Height:
5.
feet
4 1/4 inches. Weight: 170
pounds.
Color of hair:
Dark Brown Color of eyes:
Brown
Other visible distinctive marks:
none
(If no visible distinctive marks, so state.)
Where born:
Dalbeathic
Scotland
,
(City or town.)
(Country.)
Date of birth:
November
31
1871
,
(Month.)
Present residence:
smith St
(Day.) Conn (Year.)
,
(Number and street.)
(City or town.)
(State, Territory, or District.)
Emigrated from:
Leverfurl
,
England
(Place where alien got on ship or train to come to the United States.)
(Country.)
Name of vessel:
Laconia
(If the alien arrived otherwise than by vessel, the character of conveyance or name of transportation company should be given.)
Last place of foreign residence: said Dalbatte
Scotland
,
(City or town.)
(Country.)
*I am not married; the neme of my
Swife thusband) is
fshel
;
the
}
was
*born at
; and now resides at
I am now a subject of and intend to renounce allegiance to
King Write Grancin name and the of soyereign England and conntry of which
now a subject; or if citizen of a Republic, write name of Republic only.)
I arrived at the port of
N.g City or town.) York
(State or Territory.)
on or about
May
30
,
,
1889
(Month.)
(Day.)
(Year.)
* NOTE TO CLERK OF COURT.-The two lines indicated by the * contain information which is provided for by blanks on the latest
declaration of intention form; until such time as you may be supplied with forms containing these blank spaces the information called
for herein should be inserted immediately ABOVE the twelfth line, which begins It is my bona fide intention, etc., as requested in
circular letter of January 5, 1916.
GOVERNMENT PRINTING OFFICE
14-8
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"ocrText": "i\nForm 2213\nFACTS FOR DECLARATION OF INTENTION\nU.S. DEPARTMENT OF LABOR\nNATURALIZATION SERVICE\n5062\nNOTE.-A copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the\npublic-school teacher to each applicant for a declaration of intention, so that he can at his leisure fill in the answers to\nthe questions. After being filled out the applicant should take the form to the office of the clerk of court to be used\nby him in properly filling out the declaration. Care should be used to state as near as can be remembered the day,\nmonth, and year of arrival, as well as the name of the vessel on which the alien emigrated to this country.\nTO THE APPLICANT.The fee of one dollar required by law for the declaration, must be paid to the clerk of the\ncourt beforo ho commences to fill out the declaration of intention. No fee is chargeable for this blank, and none\nshould be paid for assistance in filling it out, as the Naturalization Examiner or the public-school teacher will help you\nfreo of charge.\nMy name is\nAlexander Brown\nAge: 55\nyears.\n(Alien should state here his true, original, and correct name in full.)\n(Give age at last birthday.\nAlso known as\n(If alien has used any other name in this country, that name should be shown on lino immediately above.)\nOccupation:\ngranite Cutter\nColor:\nWhite\nComplexion:\nSandy Fair\nHeight:\n5.\nfeet\n4 1/4 inches. Weight: 170\npounds.\nColor of hair:\nDark Brown Color of eyes:\nBrown\nOther visible distinctive marks:\nnone\n(If no visible distinctive marks, so state.)\nWhere born:\nDalbeathic\nScotland\n,\n(City or town.)\n(Country.)\nDate of birth:\nNovember\n31\n1871\n,\n(Month.)\nPresent residence:\nsmith St\n(Day.) Conn (Year.)\n,\n(Number and street.)\n(City or town.)\n(State, Territory, or District.)\nEmigrated from:\nLeverfurl\n,\nEngland\n(Place where alien got on ship or train to come to the United States.)\n(Country.)\nName of vessel:\nLaconia\n(If the alien arrived otherwise than by vessel, the character of conveyance or name of transportation company should be given.)\nLast place of foreign residence: said Dalbatte\nScotland\n,\n(City or town.)\n(Country.)\n*I am not married; the neme of my\nSwife thusband) is\nfshel\n;\nthe\n}\nwas\n*born at\n; and now resides at\nI am now a subject of and intend to renounce allegiance to\nKing Write Grancin name and the of soyereign England and conntry of which\nnow a subject; or if citizen of a Republic, write name of Republic only.)\nI arrived at the port of\nN.g City or town.) York\n(State or Territory.)\non or about\nMay\n30\n,\n,\n1889\n(Month.)\n(Day.)\n(Year.)\n* NOTE TO CLERK OF COURT.-The two lines indicated by the * contain information which is provided for by blanks on the latest\ndeclaration of intention form; until such time as you may be supplied with forms containing these blank spaces the information called\nfor herein should be inserted immediately ABOVE the twelfth line, which begins It is my bona fide intention, etc., as requested in\ncircular letter of January 5, 1916.\nGOVERNMENT PRINTING OFFICE\n14-8"
}