Form No. I- 55

FIELD FILE No.

U. S. DEPARTMENT OF JUSTICE IMMIGRATION AND NATURALIZATION SERVICE

9.2.1942

CENTRAL OFFICEFILE No.

( For office use.

Do not write in this space)

ALIENREGISTRATION NO.

GENERAL INFORMATION FORM

The information requested of you in this form is required to assist the Government in deciding upon yourapplication. Your application cannot be granted unless you cooperate with the Government by giving thisinformation as completely as you can. You must file with your application two copies of this form filled outand sworn to before a notary public or an immigrant inspector.

If you wish, you may take an extra copy of the form to use while you are securing the information. Then,when you are sure that you have answered all the questions clearly on this sample form, you may copy youranswers on the two forms which are to be filed.

Any immigration officer or the representative of any social service agency will be glad to explain thequestions to you and assist you in filling out this form. The answers to the questions, however, must be yourown answers and not those suggested to you by any other person. If you do not have room to answer certainof the questions in the space provided, you will find two blank sheets at the end of the form on which you mayalso write. If you write on these blank sheets, however, be sure to give the number or numbers of the questionswhich you are answering.

Be sure to answer every question. If you do not know the answer to certain of the questions and cannotfind out, write" I do not know," and then explain why you cannot secure the information.

Your attention is called to section 22( c) of the Immigration Act of 1924, which provides that whoeverknowingly makes under oath any false statement in any application, affidavit, or other document required bythe immigration laws or regulations prescribed thereunder, shall, upon conviction thereof, be fined not more than$ 10,000 or imprisoned for not more than 5 years, or both. Your answers to any of the questions in this formmay be used as evidence in any proceedings to determine your right to enter, reenter, pass through, or residein the United States . False answers to any of the questions may result in the denial of your application.

1.( a) What is

name?your

MARIE( PLEASE PRINT)( First)

( b) Under what name did you last enter the United States ?

( Middle)

MARIE JUCHACZ

( Last)

( Middle)

( c)( If you are a married woman) What was your maiden name?

( Middle)

( PLEASE PRINT)( First)TUCHACZ

( Last)

MARIE( PLEASE PRINT)( First)GOHLKE

( Last)

( d) By what names have you also been known?( Include professional names or any other names by

which you have been known.)

( PLEASE PRINT)

( 1)

NONE

16-19234