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r ,STATEMENT OF G_ _ZENSHIP, ALIENAGE, AND IMM,, _<ATION STATUS IN SUPPORT OF A REQUEST FOR STATE PUBLIC BENEFITS Print name of applicant(person who wants a license, certificate,or permit to operate) Date Print name of person acting for applicant, if any: Relationship to Applicant Type of Application: PERMIT TO OPERATE EMPLOYEE HOUSING CITIZENSHIP/IMMIGRATION STATUS DECLARATION Citizens and nationals of the United States who meet all eligibility requirements may receive Occupational Licenses, Certificates,Approvals and/or Permits to Operate and must fill out SECTIONS A and D. Aliens who meet all eligibility requirements may also receive Occupational Licenses, Certificates,Approvals and/or Permits to Operate and must complete SECTIONS A, B, and D,and if necessary, SECTION C of this form. SECTION A: CITIZENSHIP/IMMIGRATION STATUS DECLARATION 1. Are you a citizen or national of the United States? Yes No If the answer to the above question is yes,where were your bom? S tl-N City/State/Country 2. To establish citizenship or nationality please submit a legible and unaltered copy of one of the documents on List A. IF YOU ARE A CITIZEN OR NATIONAL OF THE UNITED STATES, GO DIRECTLY TO SECTION D. IF YOU ARE AN ALIEN, PLEASE COMPLETE SECTION B,AND, IF NECESSARY, SECTION C. SECTION 13: ALIEN STATUS DECLARATION IMPORTANT: Please indicate your alien status below, and submit documents evidencing such status. The alien status documents listed for each category are the most commonly used documents that the United States Immigration and Naturalization Service(INS)provides to aliens in those categories. You can provide other acceptable evidence of your alien status even if not listed below. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act(INA). Evidence includes: • INS Form 1-551 (Alien Registration Receipt Card,commonly known as a"green card"); or • Unexpired Temporary 1-551 stamp in foreign passport or on INS Form 1-94. An alien who is granted asylum under section 208 of the INA. Evidence includes: • , INS Form 1-94 annotated with stamp showing grant of asylum under section 208 of the INA; • INS Form 1-688B(Employment Authorization Card annotated"274a.1 2(a)(5)". • INS Form 1-766(Employment Authorization Document annotated"AS'. • Grant letter from the Asylum Office of INS;or • Order of an immigration judge-granting asylum. A refuge admitted to the United States under section 207 of the INA. Evidence includes: • INS Form 1-94 annotated with stamp showing admission under s207 of the INA; • INS Form 1-688B(Employment Authorization Card)annotated"274a. 12(a)(3)" • INS Form 1-766(Employment Authorization Document)annotated"AX; or • INS Form 1-571 (Refugee Travel Document). An alien paroled into the United States for at least one year under section 212(d)(5)of the INA. Evidence includes: • INS Form 1-94 with stamp showing admission for at least one year under section 212(d)(5)of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one-year requirement.) An alien whose deportation is being withheld under section 243(h)of the INA(as in effect immediately prior to September 30, 1996)of Section 241(b)(3)of such Act(as amended by section 305(a)of division C of Public Law 104-208). Evidence includes: • INS Form 1-688B(Employment Authorization Card)annotated"247a. 12(a)(10)". • INS Form 1-766(Employment Authorization Document)annotated"A10";or • Order from an immigration judge showing deportation withheld under s243(h)of the INA as in effect prior to April 1, 1997,or removal withheld under s241(b)(3)of the INA.