OMB No. 1615-0042; Expires 04/30/2014 Form I-777, Application for Replacement of Northern Mariana Card Department of Homeland Security U.S. Citizenship and Immigration Services Part 1. Information About You (Person applying for a Northern Mariana Card) Family Name (Last Name) Given Name (First Name) Middle Name FOR USCIS USE ONLY Returned Receipt Date Home Address - Street Number and Name Apt. # Date Resubmitted City Date State or Province Date Zip/Postal Code Reloc Sent Country Date Mailing Address - Street Number and Name Apt./Suite # Date Reloc Rec'd C/O (In care of): Date Date City State or Province Applicant Interviewed on Zip/Postal Code Country A-Number Daytime Phone # (Area/Country Code) Gender Male Remarks Female Date of Birth (mm/dd/yyyy) Place of Birth (City/Town and Country) A-Number (If any) U.S. Social Security # (If any) Father's First Name Mother's First Name Part 2. Action Requested Action Check the classification that best describes your eligibility. (Check one box) A. My Northern Mariana Card was lost or destroyed. B. My Northern Mariana Card was stolen. (You must attach a copy of the police report.) C. My Northern Mariana Card was damaged. (You must attach the damaged card.) To Be Completed by Attorney or Representative, if any. Fill in box if G-28 is attached to represent the applicant. ATTY State License # Form I-777 (Rev. 04/26/12) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Additional Information 1. List all absences from the Commonwealth of the Northern Mariana Islands or the United States (List absences from the present to the last) From (mm/dd/yyyy) To (mm/dd/yyyy) From (mm/dd/yyyy) Present To (mm/dd/yyyy) Present 2. At what address(es) have you lived for the last ten years? (List present address first) Street Address (Number and Name) From (mm/dd/yyyy) City, State To (mm/dd/yyyy) present Part 4. Signature (Read the information on penalties in the instructions before completing this part) I certify, under penalty of perjury of the laws of the United States of America, that my application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records that U.S.Citizenship and Immigration Services needs to determine my eligibility for the benefit I am seeking. Signature Daytime Phone Number (with area code) Date (mm/dd/yyyy) NOTE: If you do not completely fill out this form or fail to submit the required documents listed in the instructions, you may not be found eligible for the requested document, and this application may be denied. Part 5. Signature of Person Preparing Form, If Other than Above (Sign below) I declare that I prepared this application at the request of the person named above, and it is based on all information of which I have knowledge. Signature Print or Type Your Name Date (mm/dd/yyyy) Firm Name and Address E-Mail Fax Number Daytime Phone Number (with area code) Form I-777 (Rev. 04/26/12) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com