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APPLICANT'S INFORMATION
* Applicant's Full Name ( First, Middle, Last)
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* Applicant's Current Residential Address:
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* Applicant's Phone Number:
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* Applicant's Email Address:
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* Is Applicant a U.S. Citizen?
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Please email a copy of your U.S. Passport and Driver's License to my Email @ larca@fleitasarcalaw.com

ANCESTOR'S INFORMATION

QUALIFYING ANCESTOR (last relative born in Italy, who emigrated to the U.S.)
* Full Name of Ancestor:
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Degree of kinship: (father, mother, grandfather, great-grandmother, etc.)
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* Date & Place of Birth
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Date & Place of Marriage:
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Spouse's Full Name
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Citizenship at Birth:
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Spouse's Country of Birth & Citizenship
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Other citizenship acquired? (Yes/No - If Y, please provide)
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Date of Naturalization: (important)
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List all Countries & U.S. States ( as well as cities and counties, if available) where your Italian ancestor resided during his/her life:
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Date and place of Death (if applicable):
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SON/DAUGHTER OF ITALIAN ANCESTOR:

FULL NAME & Degree of Kinship:
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Date & Place of Birth:
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Citizenship at Birth:
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Other citizenship acquired? (Yes/No - If Y, please provide)
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Date of Naturalization (other than Italian):
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*IF MARRIED* - (1) Date & Place of Marriage. (2) Spouse's FULL NAME (3) Spouse's Country of Birth & Citizenship:
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List all Countries & U.S. States ( as well as cities and counties, if available) where the son/daughter of the Italian ancestor resided during his/her life:
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Date and place of Death of Son/Daughter (if applicable):
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GRANDCHILD OF ITALIAN ANCESTOR:

FULL NAME & Degree of Kinship:
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Date & Place of Birth:
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Citizenship at Birth:
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Other citizenship acquired? (Yes/No - If Y, please provide)
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Date of Naturalization (other than Italian):
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List all Countries & U.S. States ( as well as cities and counties, if available) where the grandchild of the Italian ancestor resided during his/her life:
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*IF MARRIED* - (1) Date & Place of Marriage. (2) Spouse's FULL NAME (3) Spouse's Country of Birth & Citizenship:
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Date and place of Death of Grandchild (if applicable):
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SON/DAUGHTER OF GRANDCHILD OF ITALIAN ANCESTOR:

FULL NAME & Degree of Kinship:
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Date & Place of Birth:
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Citizenship at Birth:
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Other citizenship acquired? (Yes/No - If Y, please provide)
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Date of Naturalization (other than Italian):
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List all Countries & U.S. States ( as well as cities and counties, if available) where this particular Italian ancestor resided during his/her life:
0/250
*IF MARRIED* - (1) Date & Place of Marriage. (2) Spouse's FULL NAME (3) Spouse's Country of Birth & Citizenship:
0/250
Date and place of Death of this ancestor (if applicable):
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Submit Survey
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