Free affidavit form 16
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Please return completed paperwork to:
University Enrollment Center
UMass Dartmouth
285 Old Westport Road
North Dartmouth MA 02747-2300
Phone: 508.999.8857

Citizen/Eligible Non-Citizen Affidavit Form
This form is for the collection of U.S. Department of Homeland Security (DHS) or other U.S. citizenship/ eligible noncitizenship/nationality documents from students who are unable to present their documents in person.
Student Last Name

First Name

Middle Initial

Student ID


Date of Birth

Zip Code

Phone Number

Email Address
I certify that I, __________________________ (print student name), am the individual signing this statement, and I am
providing a copy of my documents along with a copy of a valid government-issued photo identification card bearing my
portrait (or likeness). I certify that the attached documents and government issued photo identification are the true, exact,
and complete copies of the originals issued to me.

List of document(s):