Fillable Request for Status Information Letter (Palm Beach State College)

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Request for Status Information Letter (Palm Beach State College)

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Request for Status Information Letter
I am requesting a Status Information Letter. I am a male who is not registered with Selective
Service. I am now 26 years old or older, and was born after December 31, 1959.
Section 1:
Name
List any other names used
Current Mailing Address
Social Security Number
Date of Birth
Daytime Telephone Number
E-mail Address
First Middle Last
Include any multiple last names
Street Address
City State Zip Code
Month / Day / Year
Student Financial Aid
If this request for status information letter is related to the student nancial aid process, please
provide the address of the school, college, university you plan to attend or are attending.
Name of School
Street Address
City/Town
State and Zip Code
Phone Fax Number
Section 2:
MILITARY:
List dates of active duty service:
List dates of reserve duty service:
List dates of military school service:
Military school attended:
Attach copy of DD214 (or DD Form 4 if still on active duty)
INCARCERATED, INSTITUTIONALIZED, HOSPITALIZED, OR CONFINED TO HOME:
List dates during which you were (circle appropriate situation) incarcerated,
institutionalized, hospitalized, or conned to home. For multiple dates, list all.
Attach proof of each instance
NON CITIZEN / UNDOCUMENTED IMMIGRANT
Date you entered the United States for the rst time:
USCIS (Formerly INS) status at time of entry:
List all alien status(es) held since entering the country, and give dates:
(Attach separate sheet if necessary)
Attach copies of supporting documentation (see following information sheet for
detailed instructions regarding this)
TRANSSEXUAL:
At birth my gender was:
Attach copy of birth certicate
REASON WHY YOU FAILED TO REGISTER WITH SELECTIVE SERVICE UPON
REACHING AGE 18 AND BEFORE REACHING AGE 26:
to
to
to
to to to
,
,
Month / Day / Year
to
to
to
to
USCIS Status:
USCIS Status:
USCIS Status:
USCIS Status:
Section 3:
Print, sign and date, then send this letter, together with ALL copies of required documents and
any other supporting information you may wish to include to:
Selective Service System
ATTN: SIL
PO Box 94638
Palatine, IL 60094-4638
No action can be taken until we receive ALL of the information/documentation needed. You
should retain a copy of all documents and correspondence submitted to us.
Signature Date
INSTRUCTIONS
For lling out the “Request for Status Information Letter”
SECTION 1:
• Name:youmustprovideyourcompletename,andanyothernamesyouhaveeverused.Ifyouhavemorethanone
lastname,youmustprovidebothnames.
• Address:youmustincludeyourcompletemailingaddress.Formsreceivedwithoutamailingaddresswillnotbe
processed.
• SocialSecurityNumber:IfyouhaveaSocialSecurityNumber,youmustprovideit.Also,ifyouhaveeveruseda
differentSocialSecurityAccountNumber,providethataswell.
• DateofBirth:ThisformisonlyformenbornafterDecember31,1959,whoare26yearsoldorolder.Youmust
provideyourcompletedateofbirth.
• DaytimeTelephoneNumber:Ifpossible,provideatelephonenumberwhereyoucanbereachedduringtheday,in
caseweneedtocontactyou.
• E-mailAddress:Ifpossible,provideyoure-mailaddressincaseweneedtocontactyou.
SECTION 2:
ThissectionisforexplaininganddocumentingwhyyoudidnotregisterwithSelectiveService.Thissectionconsistsof
vedifferentparts.Youmustcompleteandsubmitdocumentationforanyandallpartsthatapplytoyou.
Military:
Toobtainproofofmilitaryservice(DD-214,OfcialMilitaryPersonnelFile)writeto:NationalPersonnelRecords
Center,GSA,MilitaryPersonnelRecordsCenter,9700PageBlvd.,St.Louis,MO,63132.Orvisit
http://www.archives.gov/veterans/military-service-records
Incarcerated, institutionalized, hospitalized, or conned to home:
Foreachinstance,providetypeofconnement,datesofconnement,andsupportingdocumentation.
Non Citizen / Undocumented Immigrants:
IfyouenteredtheUnitedStatesforthersttimeafteryour26thbirthday,youmustprovidedocumentationto
supportyourclaim.Validdocumentationincludes:entrystampinyourpassport,I-94withentrystamponit.Ifyou
enteredtheUnitedStatesillegallyafteryour26thbirthday,youmustprovideproofthatyouwerenotlivinginthe
UnitedStatesfromage18toage26.Pleasenote:yourResidentAlienCard(GreenCard)isnotvalidasproofof
entrytotheUnitedStates.
IfyouenteredtheUnitedStatesasavalidnon-immigrantalien,andremainedinthatstatustoyour26thbirthday,
youmustprovidedocumentationtosupportyourclaim.Forexample,ifyouenteredtheUnitedStatesasanF-1
Student,andremainedinthatstatusuntilyour26thbirthday,youwouldneedtoprovidedocumentationindicating
thatyouwereadmittedonanF-1visaandattendedschoolfull-timeasrequired.(Acceptabledocumentsforthis
situationincludecopiesofyourI-20soraletterfromtheschoolyouattendedindicatingyourfulltimeattendance
asanon-immigrantalien).Thesamethingappliesforallnon-immigrantstatuses.Youmustexplain,ifatany
point,youviolatedthetermsofyourvisa,oroverstayedyourvisaandbecameanundocumentedalien.
Youshouldprovideasmuchinformationaspossible.Wewillusetheinformationyouprovidetodetermineyour
registrationstatus.
Transsexual:
Forindividualswhohavehadasexchange.Youmustindicatewhatgenderyouwerebornas,andattach
documentationwhichindicatesthisaswell.
Reason why you failed to register with Selective Service upon reaching age 18 and before reaching age 26:
ProvideawrittenexplanationfornotregisteringwithSelectiveService.
(continued on next page)
SECTION 3:
Signanddatetheletter.Returnthislettertotheaddresslistedwithcopiesofsupportingdocuments,showingproofand
anythingelseyoumaywishtoinclude.Donotsendoriginaldocuments,astheywillnotbereturned.Youshouldretaina
copyofalldocumentsandcorrespondencesubmitted.
HELPFUL INFORMATION
• Thisformisdesignedtobeprintedforuse,andcannotbecompletedonline.Afterprinting,completetheform,attach
ALLsupportingdocumentation,andmailto:SelectiveServiceSystem,ATTN:SIL,POBox94638,Palatine,IL
60094-4638.
• ThisformisforuseonlybymenbornafterDecember31,1959,whoarenotregisteredandarenow26yearsoldor
older.
• Thisformisnotaregistrationform,andbysubmittingit,youwillnotberegistered.
• Ifyoufeelthatyouhavealreadyregistered,verifyyourregistrationonourwebsite(www.sss.gov),orcallour
RegistrationInformationOfceat(847)688-6888toobtainyourSelectiveServicenumber.
• WewillissueaStatusInformationLetterbasedontheinformationyouprovide.Thisletterwillclarifyyourstatuswith
SelectiveService.
• Ifyouarebeingdeniedaright,benet,orprivilegebecauseyouarenotregistered,submitacopyofyourstatus
informationletterandanexplanationletterforyourfailuretoregister,totheAgencyadministeringtheright,benet,or
privilege.ThatAgencywillmakethenaldeterminationregardingyoureligibility.TheSelectiveServiceSystemdoes
notdetermineyoureligibilityforanyright,benet,orprivilege.
April 24, 2014
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Request for Status Information Letter (Palm Beach State College)

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Completed 23 July 2020

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