Affidavit of U.S. Citizenship
State of ______ County of ______ SS:
I, __________, (Name) of __________, (Residence address) being duly sworn, depose and say:
Name | Title | Date and place of birth |
(The foregoing list should include the officers, whether or not they are also directors, and all directors, whether or not they are also officers.)
and that each of said individuals is a citizen of the United States by virtue of birth in the United States, birth abroad of U.S. citizen parents, by naturalization, by naturalization during minority through the naturalization of a parent, by marriage (if a woman) to a U.S. citizen prior to September 22, 1922, or as otherwise authorized by law, except (give name and nationality of alien directors, if any); however, the Bylaws of the Corporation provide that ______(Number) of the directors are necessary to constitute a quorum; therefore, the alien directors named represent no more than a minority of the number necessary to constitute a quorum. [In the case of corporations under title VI, Merchant Marine Act, 1936, as amended, all directors must be citizens of the United States. Further, obtaining evidence necessary to support this Affidavit of U.S. Citizenship is the responsibility of the affiant.];
That I have access to the stock books and records of the Corporation; that said stock books and records have been examined and disclose (a) that, as of ______, (Date) the Corporation had issued and outstanding ______ (Number) shares of ______, (Class or series) the only class or series of stock of the Corporation issued and outstanding [if such is the case], owned of record by ______(Number) stockholders, said number of stockholders representing the ownership of the entire issued and outstanding stock of the Corporation, and (b) that no stockholder owned of record as of said date five per centum (5%) or more of the issued and outstanding stock of the Corporation of any class or series. [If different classes or series of stock exist, give the same data for each class or series issued and outstanding, showing the monetary value and voting rights per share in each class or series. If there is an exception to the statement in clause (b), the name, address, and citizenship of the stockholder and the amount and class or series of stock owned should be stated.]
That the registered addresses of ______ owners of record of ______ shares of the issued and outstanding __________(Class or series) stock of the Corporation are shown on the stock books and records of the Corporation as being within the United States, said ______ shares being ______ per centum (______%) of the total number of shares of said stock (each class or series). [The exact figure as disclosed by the stock books of the corporation must be given and the per centum figure must not be less than 65 per centum, except that for a corporation operating a vessel in the coastwise trade, the per centum figure must be not less than 95 per centum. These per centum figures apply to corporate stockholders as well as to the primary corporation.]
(The same statement should be made with reference to each class or series of stock, if there is more than one class or series.)
That the information as to stock ownership, upon which the Corporation relies to establish that the required percentage of stock ownership is vested in citizens of the United States, is as follows:
Name of stockholder | Number of shares owned (each class or series) | Percentage of shares owned (each class or series) |
and that each of said individual stockholders is a citizen of the United States by virtue of birth in the United States, birth abroad of U.S. citizen parents, by naturalization during minority through the naturalization of a parent, by marriage (if a woman) to a U.S. citizen prior to September 22, 1922, or as otherwise authorized by law.
Note: If a corporate stockholder, give information with respect to State of incorporation, the names of the officers, directors, and stockholders in the appropriate percentage of shares held, with statement that they are all U.S. citizens. Nominee holders of record of 5 percent or more of any class or series of stock and the beneficial owners thereof should be named and their U.S. citizenship affirmed.
Dated: ______
(Name of affiant)
Subscribed and sworn to before me, a Notary Public in and for the State and County aforesaid, this __________ day of ______________19____.
(Notary Public)
My Commission expires:
__________________________
PENALTY FOR FALSE STATEMENT: A fine or imprisonment, or both, are provided for violation of the proscriptions contained in 18 U.S.C. 1001 (see also 18 U.S.C. 286 , 287 ).
46 C.F.R. §355.2
Approved by the Office of Management and Budget under control number 2133-0012