1. STATEMENT OF UNITED STATES CITIZEN OF ANCESTRY
1. ----------------------------------------- ------------------------------------------- --------------------------------------------
(Surname) (English given name) ( given name)
2. Date of birth ------------------------------------------------ Place of birth ------------------------------------------------------------
3. Present address ------------------------------------------------------------------------------------------------------------------------------
(Street) (City) (State)
4. Sex ---------------------------------- Height -------------------------------------------------- Weight ----------------------------------
5. Marital status ------------------------------ Citizenship of wife ---------------------------------- Race of wife ----------------------
In items 6 and 7, 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.
6. Relatives in the United States (if in military service, indicate whether a selectee or volunteer):
(a) ----------------------------------------------------------------------------------------------------------------------------- (Name) (Relationship to you) (Citizenship)
----------------------------------------------------------------------------------------------------------------------------- (Complete address) (Occupation) (Volunteer or selectee)
(b) ----------------------------------------------------------------------------------------------------------------------------- (Name) (Relationship to you) (Citizenship)
-----------------------------------------------------------------------------------------------------------------------------
(Complete address) (Occupation) (Volunteer or selectee)
(If additional space is necessary, attach sheets)
Form Approved
Budget Bureau No. 33-R045-43
(Loxal Board Date Stamp With Code)
Dss Form 304A
(1-23-43)
16—32563—1
Disclaimer:
The questions seen on this survey are a small sampling of the questions that were asked of the Japanese internees. Unlike
us, internees could not refuse to answer questions that made them uncomfortable. As you look through the questions, take
special note of the empty parentheses that we have used in place of the name “Japanese.” When you see the parentheses,
imagine using the name of another group of which you are a part, or with which you identify strongly, in its place. Think about
how Internees might have felt answering these questions, and about how you, personally, might answer.
At the end of the night, please feel free to take your survey with you. We are not cataloging your responses, and want you to
know that this survey was intended only to give you first-hand experience similar to that of the Internees as they answered the
questions on the Loyalty questionnaire.
We apologize if this survey offended you in any way. Once again, we would like to assure you that our intention was only to
teach. Once again, we would like to thank you for attending our symposium and for taking the time to fill out our survey.
Sincerely,
The Contemporary Investigation of the Japanese Internment Camps class

2. 7. Relatives in (see instruction above item 6):
(a) -----------------------------------------------------------------------------------------------------------------------------
(Name) (Relationship to you) (Citizenship)
-----------------------------------------------------------------------------------------------------------------------------
(Complete address) (Occupation)
8. Foreign travel (give dates, where, how, for whom, with whom, and reasons therefore):
---------------------------------------------------------------------------------------------------------------------------------------------
9. Religion ------------------------------------------------ Membership in religious groups ------------------------------------------------
10. Knowledge of foreign languages (put check mark (√ ) in proper squares):
11. Give details on any foreign investments.
(a) Accounts in foreign banks. Amount, $ ------------------------------------------
Bank ------------------------------------------ Date account opened ------------------------------------------
(b) Investments in foreign companies. Amount, $ ------------------------------------------
Company ------------------------------------------ Date acquired ------------------------------------------
(c) Do you have a safe-deposi box in a foreign country?
What country? ------------------------------------------ Date acquired ------------------------------------------
Contents ----------------------------------------------------------------------------------------------------------------
12. To the best of your knowledge, was your birth ever registered with any governmental agency for the purpose
of establishing a claim to citizenship? -------------------------------------------------------------------------------------
(a) If so registered, have you applied for cancelation of such registration? ------------------------------------------------
(Yes or No)
When? ------------------------------------------- Where? ----------------------------------------------------------------------
13. Are you willing to serve in the armed forces of the United States on combat duty, wherever ordered? ---------------------
14. 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 of obedience to the
or any other foreign government, power, or organization? -------------
------------------------------------------------- -------------------------------------------------
(Date) (Signature)
NOTE. — Any person who knowingly and wilfully falsifies or conceals a material fact or makes a false or fraudulent
statement or representation in any matter whithin the jurisdiction of any department or agency of the United States is liable
to a fine or not more than $10,000 or 10 years imprisonment, or both.
U. S. Government Printing Office 16—32563—1
(a) Good Fair Poor (b) Other ------------- Good Fair Poor
(Specify)
Reading
Writing
Speaking
Reading
Writing
Speaking