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Form 2213
FACTS FOR DECLARATION OF INTENTION
U. S. DEPARTMENT OF LABOR
NATURALIZATION SERVICE
5287
NOTE.-A copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the
public-school toacher to each applicant for a doclaration 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. Caro 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.-Th fee of one dollar required by law for the declaration, must be paid to the clerk of the
court before he 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
free of charge.
My name is Bessie Safenowitz
Age: 42
years.
(Alien should state here his true, original, and correct name in fuli.)
(Give age at last birthday.)
Also
known as Bessie Chazen
(If alien has used any other name in this conntry, that name should be shown on line immediately above.)
Occupation:
House Keepen wife
Color: White
Complexion: Dark
Height: Five
feet
I
inches W° efght: 123
pounds.
Color of hair: Black
Color of eyes: Brown
dark
Other visible distinctive marks: none
Where born: Volkomin
,
Russia, (If no now Lithuania marks, so
visible distinctive state.
(City or town.)
(Country.)
Date of birth: July
5
, 1885
,
(Month.)
(Day.)
(Year.)
Present residence: 24 Elizabeth St, Norwich
Connecticut
,
(Number and street.)
(City or town.)
(State, Territory, or District.)
Emigrated from: Rotterdam
Holland
(Place where alien got on ship or train foome to the United States.
(Donothnow)
(Country.)
Name of vessel:
(If
the
alien
arrived
otherwisethan by character of veyance orname of transportation company should be given.)
Last place of foreign residence:
said vessel, the Volkomr
(City or town.)
(Country.)
*I am
married; the name of my twife thrusband) is Kaleman Safenowits (he was
*born at Kupiska; Russia ; and now résides at 24 Elizabeth
said
St.
I am now a subject of and intend to nenounce allegiance to
Fovernment
of RUSCH (Write name and title of sovereign the and Republic countr yl of which now a subject; or of ifcitizen of a thuama Republic, write name of Republic
only.)
I arrived at the port of New
York
,
N. Y.
City or town.)
(State or Territory.)
on or about June
10
, 1904
,
(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.
GOVEENMENT PRINTING OFFICE
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"ocrText": "Form 2213\nFACTS FOR DECLARATION OF INTENTION\nU. S. DEPARTMENT OF LABOR\nNATURALIZATION SERVICE\n5287\nNOTE.-A copy of this form will be furnished by the clerk of the court, the Chief Naturalization Examiner, or the\npublic-school toacher to each applicant for a doclaration 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. Caro 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.-Th fee of one dollar required by law for the declaration, must be paid to the clerk of the\ncourt before he 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\nfree of charge.\nMy name is Bessie Safenowitz\nAge: 42\nyears.\n(Alien should state here his true, original, and correct name in fuli.)\n(Give age at last birthday.)\nAlso\nknown as Bessie Chazen\n(If alien has used any other name in this conntry, that name should be shown on line immediately above.)\nOccupation:\nHouse Keepen wife\nColor: White\nComplexion: Dark\nHeight: Five\nfeet\nI\ninches W° efght: 123\npounds.\nColor of hair: Black\nColor of eyes: Brown\ndark\nOther visible distinctive marks: none\nWhere born: Volkomin\n,\nRussia, (If no now Lithuania marks, so\nvisible distinctive state.\n(City or town.)\n(Country.)\nDate of birth: July\n5\n, 1885\n,\n(Month.)\n(Day.)\n(Year.)\nPresent residence: 24 Elizabeth St, Norwich\nConnecticut\n,\n(Number and street.)\n(City or town.)\n(State, Territory, or District.)\nEmigrated from: Rotterdam\nHolland\n(Place where alien got on ship or train foome to the United States.\n(Donothnow)\n(Country.)\nName of vessel:\n(If\nthe\nalien\narrived\notherwisethan by character of veyance orname of transportation company should be given.)\nLast place of foreign residence:\nsaid vessel, the Volkomr\n(City or town.)\n(Country.)\n*I am\nmarried; the name of my twife thrusband) is Kaleman Safenowits (he was\n*born at Kupiska; Russia ; and now résides at 24 Elizabeth\nsaid\nSt.\nI am now a subject of and intend to nenounce allegiance to\nFovernment\nof RUSCH (Write name and title of sovereign the and Republic countr yl of which now a subject; or of ifcitizen of a thuama Republic, write name of Republic\nonly.)\nI arrived at the port of New\nYork\n,\nN. Y.\nCity or town.)\n(State or Territory.)\non or about June\n10\n, 1904\n,\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.\nGOVEENMENT PRINTING OFFICE"
}