United States Citizenship Attestation Form
This information is provided by the Nebraska Department of Environmental Quality  
to assist the public and regulated community .

Form #:  09-012
Applications and Forms
Revised: 8/18/14


Effective Oct. 1, 2009, any individual submitting any application or form that would derive public benefit from the state must also fill out this United States Citizenship Attestation Form. This applies to individuals submitting the forms on their own behalf. If applicable, please submit this with the relevant applications and forms.