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5462 Form 2213 FACTS FOR DECLARATION OF INTENTION U.S. DEPARTMENT OF LABOR DCT 25 1928 NATURALIZATION SERVICE 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 tako the form to the office of the clork of court to be used by him in properly filling out the declaration. Care should be used to state as near as can bo 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.-Th fee of one dollar required by law for the declaration, must be paid to the clerk of the court before ho commences to fill out the declaration of intention. No feo 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 free of charge. My name is Jackary (Alien true, Baranoff original, and in full Age: 33 years. should state heralis correct name (Give age at last birthday.) Also known none as (If alien nas used any other name in this country, that name should be shown on line immediately above.) Occupation: Ship Driller Color: White Complezion: Fair Height: 5 feet 86 inches. Weight: 190 pounds. Color of hair: Light Browen Color of eyes: Blue Other visible distinctive marks: none (If no.visible distinctive marks so state.) Where born: Bakshtg Russia , (City or town.) (Country.) Date of birth: august / 1895 , (Month,) (Day.) (Year.) Present residence: 163 n.Bank new London , bonn. (Number and street.) (City or town.) (State, Territory, or District.) Emigrated from: Bremen (Place where alien got on ship or train to come to the United States.) Germany (Commtry. Name of vessel: Llo not Remember (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: Bakshty Russia , (City or town.) (Country.) *I am married; the name of my Swife (husband) is anna (she) the was *born at Bakabity, Russia ; and now resides at 163n.Bank, new London, let. I intend to renounce to Poland am now a subject of and allegiance (Write name and title of sovereign and country of which now a subject; or if citizen of a Republic, write name of Republic only.) I arrived at the port of new (City town.) march York , or n.y. (State or Territory.) on OT about about, 15 , , 1913 (Month.) (Day.) (Year.) * NOTE TO CLERK OF COURT.-The - two lines indicated by the * contain information which is provided 10r 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. 14-8

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    "ocrText": "5462\nForm 2213\nFACTS FOR DECLARATION OF INTENTION\nU.S. DEPARTMENT OF LABOR\nDCT 25 1928\nNATURALIZATION SERVICE\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 tako the form to the office of the clork of court to be used\nby him in properly filling out the declaration. Care should be used to state as near as can bo 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.-Th fee of one dollar required by law for the declaration, must be paid to the clerk of the\ncourt before ho commences to fill out the declaration of intention. No feo is chargeable for this blank, and none\nshould\nbe\npaid for assistance in filling it out, as the Naturalization Examiner or the public-school teacher will help you\nfree of charge.\nMy name is Jackary (Alien true, Baranoff original, and in full\nAge:\n33\nyears.\nshould state heralis correct name\n(Give age at last birthday.)\nAlso known none\nas\n(If alien nas used any other name in this country, that name should be shown on line immediately above.)\nOccupation: Ship Driller\nColor:\nWhite\nComplezion: Fair\nHeight:\n5\nfeet 86\ninches. Weight:\n190\npounds.\nColor of hair: Light Browen Color of eyes: Blue\nOther visible distinctive marks: none\n(If no.visible distinctive marks so state.)\nWhere born:\nBakshtg\nRussia\n,\n(City or town.)\n(Country.)\nDate of birth:\naugust\n/\n1895\n,\n(Month,)\n(Day.)\n(Year.)\nPresent residence: 163 n.Bank new London , bonn.\n(Number and street.)\n(City or town.)\n(State, Territory, or District.)\nEmigrated from: Bremen\n(Place where alien got on ship or train to come to the United States.)\nGermany\n(Commtry.\nName of vessel:\nLlo not Remember\n(If the alien arrived otherwise than by vessel the character, of conveyance or name of transportation company should be given.)\nLast\nplace of foreign residence:\nBakshty\nRussia\n,\n(City or town.)\n(Country.)\n*I am\nmarried; the name of my Swife (husband) is\nanna\n(she)\nthe\nwas\n*born at Bakabity, Russia ; and now resides at 163n.Bank, new London, let.\nI intend to renounce to Poland\nam now a subject of and allegiance\n(Write name and title of sovereign and country of which now a subject; or if citizen of a Republic, write name of Republic only.)\nI arrived at the port of\nnew (City town.)\nmarch\nYork\n,\nor\nn.y.\n(State or Territory.)\non OT about\nabout, 15\n,\n,\n1913\n(Month.)\n(Day.)\n(Year.)\n* NOTE TO CLERK OF COURT.-The - two lines indicated by the * contain information which is provided 10r 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.\n14-8"
}