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Iding at (street and number) (city) (state) (zip code if in U.S.) (country) being duly sworn depose and say: 1. I was born on (date) at (city, country) If you are not a native born United States citizen, answer the following as appropriate: A. If a United States citizen through naturalization, give certificate of naturalization number B. If a United States citizen through parent(s) or marriage, give citizenship certificate number C. If United States citizenship was derived by some other m.

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