Citizenship Certification is required with submission of an application for Designation as an Exchange Visitor Program Sponsor
FOR ALL RESPONSIBLE AND ALTERNATIVE RESPONSIBLE OFFICERS
Note: A Notary Public must attest to this Citizenship Certification
I hereby certify that I am the responsible officer / alternate responsible officer (specify which office you hold) for exchange visitor program ____________________, and that I am a United States citizen or permanent resident. I understand that the United States Department of State may request supporting documentation to my citizenship or permanent residence at any time and that I must supply such documentation when and as requested.
_________________________________________________ (Name of Organization) agrees that my inability to substantiate the representation of citizenship or permanent residence made in this certification will result in the immediate withdrawal of its designation and immediate return of and/or accounting for all Forms DS-2019 disbursed to it.
I also understand that false certification may subject me to criminal prosecution under 18 U.S.C 1001, which reads:
"Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.
Signed in Ink by
_____________________________________________ (Name)
_____________________________________________ (Title)
Witness: ______________________________________
This _______ day of ____________________, 20_____
Subscribed and sworn to before me This _______ day of ____________________, 20_____
_____________________________________________ (Notary Public)
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