CITIZENSHIP121&,7,=(1:,7+
(/,*,%/(,00,*5$7,2167$786 DECLARATION
I certify that the above information is true and accurate, and that supporting documentation can be provided upon request. _________________________ __________ ____________________________ ______ Applicant’s Signature Date Agency’s Approval Date
I, hereby declare, under penalty of perjury, that I am:
(print or type first name, middle initial, and last name) _____ 1. CITIZEN OR NATIONAL OF THE UNITED STATES If you check this block, VLgn and date 'HFODUDWLRQ and forward one of the below listed documents as proof of citizenship or naturalization to the name and address specified for the program.
_____ If this block is checked on behalf of a child, the adult who is responsible for the child should provide proof of citizenship and sign and date the 'HFODUDWLRQ.
o US passport: Both valid and expired passports may be used. If your appearance has changed significantly since your passport was issued, you may need to submit a different form of proof of US citizenship. o Original or Certified copy of US birth certificate: showing birth in the US – This must be an original or certified copy of the long-form certificate showing parents’ names, issued by the municipality in which you were born.
o Certificate of Citizenship: Original or certified copy is or those who acquired citizenship at birth or through other means.
o US Naturalization Certificate: Original or certified copy is for those who naturalized o Consular Report of Birth Abroad: if you were born overseas to a US parent, you can submit an original Consular Record of Birth Abroad (Form FS-240) or Certification of Report of Birth (Form DS-1350).
OR
_____ 2. NON - CITIZEN WITH ELIGIBLE IMMIGRATION STATUS If you check this block, Sign and date 'HFODUDWLRQ and forward one of the listed documents as proof of legal immigration status to the name and address specified for the program as evidenced by one of the documents listed below:
1. Form I-551, Permanent Resident Card
2. Form I-94, Arrival-Departure Record, with one of the following annotations:
a. “Admitted as Refugee Pursuant to section 207”
b. “Section 208” or “Asylum”
c. “Section 243(h)” or “Deportation stayed by Attorney General” or d. “Paroled Pursuant to Sec. 212(d)(5) of the INA.”
3. If Form I-94, Arrival-Departure Record, is not annotated, it must be accompanied by one of the following documents:
a. A final court decision granting asylum (but only if no appeal is taken) b. A letter from an DHS asylum officer granting asylum (if application was filed on or after October 1, 1990) or from an DHS district director granting asylum (if application was filed before October 1, 1990)
c. A court decision granting withholding or deportation or d. A letter from an DHS asylum officer granting withholding of deportation (if application was filed on or after October 1, 1990)
4. A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and that the applicant’s entitlement to the document has been verified.
5. Other acceptable evidence. If other documents are determined by the DHS to constitute acceptable evidence of eligible immigration status, they will be announced by notice published in the Federal Register.