VERIFICATION OF ELIGIBILITY

	The undersigned hereby certifies that:

	He/She is:
	( ) a descendant of the indigenous people of Hawaii.
		Provide at least 3 generations of ancestry, a birth 
certificate, baptismal paper, medical records, or 
verification by two Hawaiian citizens supporting this 
claim.

	( ) a descendant of a Hawaiian citizen who was such on or before 
16 January 		1893.
		Provide name of said ancestor(s) and the genealogical 
pattern under which you claim descendance.

	( ) a person born in Hawaii.
		Provide a birth certificate or other record verifying 
your place of birth or the statement of two witnesses to 
your birth.

	( ) 	a person who has maintained Hawaii as his only residence 
for the five years immediately preceding this declaration 
of Hawaiian Citizenship and who has met all of the 
Hawaiian naturalization requirements.
		Provide verification of at least two witnesses to the fact 
of your continued residence in Hawaii for the past five 
years.  Provide also, proof of one of the following: i) 
your marriage to a Hawaiian citizen, ii) your 
parentage to a child born in Hawaii who has taken out 
citizenship in Hawaii, iii) your having lived in Hawaii 
at least 1/3 of your lifetime to date or 15 years, iv) 
your having successfully passed the citizenship 
evaluation process.

	Dated: ________________________, Hawaii  
______________________, 199___.



		___________________________
			(sign)
		Declarant (print name):  
______________________________



Filing fee:  $25.00 (Payable to Institute for the Advancement of 
Hawaiian Affairs or IAHA)




	Confidential information:

Name given at birth:  
__________________________________________________________

Name taken by you after birth:  
_________________________________________________

Date and place of birth:  
_______________________________________________________

Current residence:  
____________________________________________________________

Permanent residence: 
__________________________________________________________

Last place of residence before Hawaii:  
__________________________________________

Telephone/facsimile number:  
___________________________________________________

Your current occupation:  
______________________________________________________

Specialized area of work you are qualified to do:  
_________________________________

Areas of work for the Hawaiian nation you are willing to do:  
_______________________

____________________________________________________________
__________________

Languages you are able to work with:  
____________________________________________

Places of travel and years of residence in such places:  
_____________________________

Political experience:  
__________________________________________________________

Military experience: 
___________________________________________________________

Media experience:  
____________________________________________________________

Licenses issued: 
____________________________________________________________
___

Real or personal property which can be contributed in whole or for a 
term of years to assist in developing the nation of Hawaii:

____________________________________________________________
__________________