United States Citizenship Attestation Form

For the purpose of complying with Neb. Rev. Stat §§ 4-108 through 4-114, I attest as follows:

I am a citizen of the United States.

- OR -

I am a qualified alien under the federal Immigration and Nationality Act, my immigration status and
alien number are as follows:
and I agree to provide a copy of my USCIS documentation upon request.

I hereby attest that my response and the information provided on this form and any related application for public benefits are true, complete, and accurate, and I understand that this information may be used to verify my lawful presence in the United States.

Print Name:
(First, Middle and Last)
Address:
(Street or PO Box)
(City, State and Zip)

Applicant’s Signature:	Date:

Attach form to contract, permit, license, etc.

FOR OFFICE USE ONLY
PROJECT DEVELOPMENT DIVISION	ORIGINATING DIVISION OR DISTRICT
SAVE Determination: Authorized Rejected Agreement No.	If the applicant marks qualified alien, send the form to Project Development Division for verification. Benefit: Contract or Agreement Janitorial Mowing Other: Haying Permit Licenses for Superintendent Relocation Assistance
Signature	Date

NDOT Form 289, November 2020