J07 - Sample AFFIDAVIT OF UNITED STATES CITIZENSHIP.docx

AFFIDAVIT OF UNITED STATES CITIZENSHIP

State of County of SS:

I, _________________________, (Name) of _____________________, (Residence address) being duly sworn, depose and say:

1. That I am the _________________(Title of office(s) held) of _____________________, (Name of corporation) a corporation organized and existing under the laws of the State of ______ (hereinafter called the "Corporation"), with offices at ___________________________, (Business address) in evidence of which incorporation a certified copy of the Articles or Certificate of Incorporation (or Association) is filed herewith (or has been filed) together with a certified copy of the corporate Bylaws. [Evidence of continuing U.S. citizenship status, including amendments to said Articles or Certificate and Bylaws, should be filed within 30 days after the annual meeting of the stockholders or annually, within 30 days after the original affidavit if there has been no meeting of the stockholders prior to that time.];

2. That I am authorized by and in behalf of the Corporation to execute and deliver this Affidavit of U.S. Citizenship;

3. That the names of the President or other Chief Executive Officer, Vice Presidents or other individuals who are authorized to act in the absence or disability of the President or other Chief Executive Officer, the Chairman of the Board of Directors, and the Directors of the Corporation are as follows:

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.

4. Information as to stock, where Corporation has 30 or more stockholders:

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 of record owned 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. This per centum figure applies 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.)

5. Information as to stock, where Corporation has less than 30 stockholders:

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 Percentage of shares owned (each class or series) (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.

6. That the controlling interest in (each) said Corporation, as established by the data hereinbefore set forth, is owned by citizens of the United States; that the title to a majority of the stock of (each) said Corporation is vested in citizens of the United States free from any trust or fiduciary obligation in favor of any person not a citizen of the United States; that such proportion of the voting power of (each) said Corporation is vested in citizens of the United States; that through no contract or understanding is it so arranged that the majority of the voting power of (each) said Corporation may be exercised, directly or indirectly, in behalf of any person who is not a citizen of the United States; and that by no means whatsoever, is control of (each) said Corporation conferred upon or permitted to be exercised by any person who is not a citizen of the United States; and

7. That affiant has carefully examined this affidavit and asserts that all of the statements and representations contained therein are true to the best of his knowledge, information, and belief.

Dated: ______ (Name of affiant) Subscribed and sworn to before me, a Notary Public in and for the State and County aforesaid, this ___ day of _______ year _______.

(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).