DSS Form 304A — Statement of United States Citizen of Japanese Ancestry

Complete all fields. Leave no item blank. Print clearly.

1. Name

Surname

English Given Name

Japanese Given Name

(a) Alias

2. Local Selective Service Board

Number

City

County

State

3. Date and Place of Birth

Date of Birth

Place of Birth

4. Present Address

Street

City

State

5. Last two addresses at which you lived 3 months or more (exclude residence at relocation center and assembly center)

Address 1

Address

From

To

Address 2

Address

From

To

6. Physical Description

Sex

Height

Weight (lbs)

Please complete all required fields before continuing.

Answer each item fully. Use "N/A" if not applicable.

7. Voter Registration

Are you a registered voter?

Year First Registered

Where?

Party

8. Marital Status

Marital Status

Citizenship of Wife

Race of Wife

9. Father's Information

Father's Name

Town or Ken (Birthplace)

State or Country

Occupation

10. Mother's Information

Mother's Name

Town or Ken (Birthplace)

State or Country

Occupation

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In items 11 and 12, you need not list relatives other than your parents, your children, your brothers and sisters. For each person give name; relationship to you (such as father); citizenship; complete address; occupation.

11. Relatives in the United States (if in military service, indicate whether a selectee or volunteer)

Relative (a)

Name

Relationship

Citizenship

Complete Address

Occupation

Volunteer or Selectee?

Relative (b)

Name

Relationship

Citizenship

Complete Address

Occupation

Volunteer or Selectee?

Relative (c)

Name

Relationship

Citizenship

Complete Address

Occupation

Volunteer or Selectee?

12. Relatives in Japan

Relative (a)

Name

Relationship

Citizenship

Complete Address

Occupation

Relative (b)

Name

Relationship

Citizenship

Complete Address

Occupation

List all schools attended. Include years of attendance for each.

13. Education

Level	Name of School	Place	From	To
Kindergarten
Grade School
Japanese Language School
High School
College / University

Military Training (e.g. R.O.T.C. or Gunji Kyoren — where and when)

Other Schooling

Description

Years of Attendance

Be specific. Include dates, locations, purposes, and names of persons involved.

14. Foreign Travel (give dates, where, how, for whom, with whom, and reasons therefor)

15. Employment (give employers' names and kind of business, addresses, and dates from 1935 to date)

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Answer fully. Use additional sheets if necessary.

16. Religion

Religion

Membership in Religious Groups

17. Membership in Organizations (clubs, societies, associations, etc. — give name, kind of organization, and dates of membership)

18. Knowledge of Foreign Languages (check appropriate box)

	Japanese			Other (specify):
	Good	Fair	Poor	Good	Fair	Poor
Reading
Writing
Speaking

19. Sports and Hobbies

List five references, other than relatives or former employers.

20. References (give address, occupation, and number of years known)

Reference 1

Name

Complete Address

Occupation

Years Known

Reference 2

Name

Complete Address

Occupation

Years Known

Reference 3

Name

Complete Address

Occupation

Years Known

Reference 4

Name

Complete Address

Occupation

Years Known

Reference 5

Name

Complete Address

Occupation

Years Known

ERROR: Fewer than 5 references detected. This field requires exactly 5 references. Please complete all entries.

Answer truthfully and completely. Failure to disclose is a federal offense.

21. Criminal Record

Have you ever been convicted by a court of a criminal offense (other than a minor traffic violation)?

No Yes

Disclose all foreign financial interests. "None" is an acceptable answer.

22. Foreign Investments

(a) Accounts in Foreign Banks

Amount ($)

Bank Name

Date Account Opened

(b) Investments in Foreign Companies

Amount ($)

Company Name

Date Acquired

(c) Safe-Deposit Box in Foreign Country

What Country?

Date Acquired

Contents

List all contributions made to any society, organization, or club.

23. Contributions to Organizations

Organization	Place	Amount ($)	Date

List all publications you have subscribed to or have regularly read.

24. Magazines and Newspapers

Answer truthfully. These questions concern your citizenship status.

25. Japanese Citizenship Registration

To the best of your knowledge, was your birth ever registered with any Japanese governmental agency for the purpose of establishing a claim to Japanese citizenship?

No Yes

26. Repatriation to Japan

Have you ever applied for repatriation to Japan?

No Yes

Read each statement carefully. Your response is legally binding.

27. Are you willing to serve in the armed forces of the United States on combat duty, wherever ordered?

Yes No

ERROR: Response not recorded. Please try again.

28. Will you swear unqualified allegiance to the United States of America and faithfully defend the United States from any or all attack by foreign or domestic forces, and forswear any form of allegiance or obedience to the Japanese emperor, or any other foreign government, power, or organization?

Yes No

ERROR: Response not recorded. Please try again.

Review your answers carefully before signing. Once submitted, this form cannot be changed.

Signature

Initials:

Type your initials to certify that the above statements are true.

FORM SUBMITTED

Your statement has been received. Retain a copy for your records.